- Which of the following tasks can be assigned to an experienced certified nursing assistant (CNA) who is helping to care for a patient on a ventilator?
- Document lung sounds every 4 hours
- Report when the endotracheal tube requires suctioning
- Check ventilator settings with the respiratory therapist
- Measure vital signs and pulse oximetry readings every 4 hours
Correct answer: Measure vital signs and pulse oximetry readings every 4 hours
A certified nursing assistant's educational preparation includes measurement of vital signs, including how to check oxygen saturation by pulse oximetry. Tasks beyond the CNA's education level are outside the CNA's scope of practice. Assessing and observing the patient, checking ventilator settings, and Suctioning require the additional education and skills of an RN.
- A client presents to the Emergency Department with an oxygen saturation (SaO2) of 78%. The client is able to breathe without assist. What oxygen delivery system will BEST increase the client's SaO2?
- Non-rebreather mask
- Simple face mask
- Nasal cannula
- Venturi mask
Correct answer: Non-rebreather mask
A normal O2 saturation is >94%. When SaO2 is below normal, the 02 delivery system depends on the SaO2 level. A nasal cannula is a low-flow device used for mild hypoxia. It can be set between 1-6 liters per minute (LPM), delivering 24-40% FiO2 FiO2 is the fraction of inspired oxygen, the concentration of oxygen in the gas mixture. The gas mixture at room air has a fraction of inspired oxygen of 21%. A simple face mask is also a low-flow device, set between 5-10 LPM, delivering 35-55% FiO2 A non-rebreather mask uses a reservoir bag and one-way valves to deliver the highest concentration of oxygen of these options; the valves prevent inhalation of expired air. It is set between 10-15 LPM (80-95% FiO2) and is the best choice for a severely hypoxic client (SaO2 78%) who can still breathe on their own. A Venturi mask is a high-flow device that delivers a precise measurement of O2. It has different sized ports to change the amount of FiO2 from 24-50%.
- When sharing a patient's medical history and care information with another provider, how much can the initiating provider disclose?
- Only data related to the other provider's specialty
- The minimum information necessary
- The patient's entire medical record
- Only current test results and progress notes
Correct answer: The minimum information necessary
When discussing and sharing a patient's information, share only enough information to allow for safe and appropriate treatment. Any information not related to care must be protected.
- An adult female client with a severe mental developmental delay will be scheduled for surgery. Which action should the nurse take first to obtain informed consent?
- Ask the surgeon to proceed with informed consent
- Verify the identity of the client's legal guardian
- Check state guidelines for the definition of mental competence
- Provide details about consent and advance directives
Correct answer: Verify the identity of the client's legal guardian
It is the surgeon's responsibility to provide informed consent. The nurse's role in obtaining informed consent is to verify the identity of the person who can provide it, so legal documents will be valid. Mental competency is determined outside the healthcare setting, as is information about informed consent and advance directives. If clients or guardians have questions, the nurse can direct them elsewhere.
- Before a patient is transported to surgery, the operating room calls the unit nurse to administer the preoperative medication as ordered. After giving the medication, the unit nurse discovers that the patient did not sign the surgical consent. What should the nurse do first?
- Ask the patient to sign the consent before transport
- Notify the surgeon
- Call the OR to cancel the procedure
- Notify the nursing supervisor
Correct answer: Notify the nursing supervisor
When reporting an incident, start with the next person in the chain of command. Depending on the facility, you may need to complete a report for the Quality Improvement or Risk Management departments. The nursing supervisor may assume responsibility for the process or ask the nurse to notify the surgeon and OR.
- The Code of Ethics for Nurses was written and published by the
- American Nurses Association
- National League for Nursing
- American Medical Association
- National Institutes of Health
Correct answer: American Nurses Association
The American Nurses Association (ANA) Code of Ethics describes the obligations and duties of every nurse. It is the nursing profession's non-negotiable ethical standard. The Code of Ethics was most recently revised in 2025 (10 provisions). The ANA was founded in 1898. The National League for Nursing was founded in 1893.
- The charge nurse is making assignments for the shift. A young client who has remained unresponsive after sustaining a traumatic brain injury will be transferred from the hospital to a long-term care facility. Which staff member is MOST appropriate to provide care for this client today?
- Unlicensed assistive personnel
- Licensed practical nurse
- Registered nurse
- Supervised nursing student
Correct answer: Registered nurse
A registered nurse should care for this client and coordinate the transfer to the long-term care facility. RNs are responsible for performing procedures to safely transfer a client, receive and transcribe HCP orders, provide information for hand-off of clients, assess the need for referrals, and maintain client confidentiality and privacy. The RN may also assess the need for referrals and identify appropriate community resources. For the transfer of this young client, the RN will identify and include necessary documents, and communicate with staff at the long-term care facility.
- The clinic nurse calls a client who has missed two check-up appointments for her baby. The mother states that she has problems with transportation. The nurse should refer the mother to
- The local volunteer agency
- The client's primary care provider
- The clinic social worker
- Her health insurance company
Correct answer: The clinic social worker
The clinic social worker should know of community resources that can assist the client. These may include a local volunteer agency that provides transportation for medical appointments.
- A new unlicensed assistive personnel (UAP) takes an oral temperature of a client and notes that it is 102 °F (38.9 °C). The UAP quickly approaches the nurse to report the temperature, telling the nurse that the previous reading was 99.2 °F (37.3 °C). The nurse enters the client's room to perform an assessment and sees the client drinking a cup of hot tea. What instruction should the nurse give to the UAP?
- In the future, offer the client ice chips instead of a hot beverage
- Provide water and juice to bring down the client's temperature
- Document both temperatures on the client's record
- Remove the tea and retake the client's temperature in 20 minutes
Correct answer: Remove the tea and retake the client's temperature in 20 minutes
Wait at least 1 hour after heavy exercise or a hot bath before measuring body temperature. Wait for 20 to 30 minutes after smoking, eating, or drinking a hot or cold liquid.
- A client is admitted with a diagnosis of central diabetes insipidus, related to insufficient secretion of antidiuretic hormone (ADH). Which urine specific gravity result supports the diagnosis?
Correct answer: 1.002
A urinary specific gravity of 1.005 or less and a urinary osmolality of less than 200 mOsm/kg are indicators of diabetes insipidus. Diabetes insipidus is caused by a lack of antidiuretic hormone (ADH), also called vasopressin, which prevents dehydration, or the kidney's inability to respond to ADH. ADH enables the kidneys to retain water in the body. When diabetes insipidus is caused by a lack of ADH, it is called central diabetes insipidus. This form of the disease can be caused by damage to the hypothalamus or pituitary gland. The normal range for urine specific gravity is 1.005 to 1.030.
- A nurse working in a remote setting relies on telemedicine communication to provide care and education for clients. What is a PRIMARY benefit of using telemedicine from the client's perspective?
- Telemedicine removes time and distance barriers to receiving care
- Technology costs are high, but access offsets the expense
- Clients are more inclined to learn about their conditions
- Health care records are automatically standardized
Correct answer: Telemedicine removes time and distance barriers to receiving care
The benefits of telemedicine (telehealth, video conference) for patients include the following: 1. No transportation time or expenses. 2. No time lost from work. 3. No child or elder care issues. 4. Easier scheduling or on-demand capability. 5. Access to specialists. 6. Reduced risk of disease transmission. Telemedicine is useful in many settings, not just remote or rural areas. Technology is not more expensive, clients can use a phone, email, or video. There is no guarantee of increased motivation or health record standardization.
- Which type of law deals with felonies and misdemeanors?
- Criminal law
- Statutory law
- Common law
- Administrative law
Correct answer: Criminal law
Criminal law deals with those who are suspected of committing misdemeanors and felonies. Statutory law involves legislative bodies. Common law is based on previous legal cases. Administrative law is determined by administrative bodies, such as state nursing boards.
- An arterial line may be used for all the following purposes EXCEPT
- Arterial blood gas tests
- Measuring cardiac output
- Continuous blood pressure monitoring
- Laboratory test blood draws
Correct answer: Measuring cardiac output
An arterial line ("art line") is a small catheter, similar to an intravenous, that is inserted into an artery. They are commonly used in critical care for several purposes: arterial blood tests, such as blood gases (ABG), easy blood draws for laboratory tests, closed blood pressure monitoring. Cardiac output can be measured with a pulmonary artery catheter, such as a SwanGanz catheter.
- The nurse is explaining to a new Certified Nursing Assistant (CNA) the purposes of applying wrist or ankle restraints to clients. Which statement by the CNA indicates to the nurse that further training is needed?
- The restraints are necessary to limit arm or leg movement
- We put on the restraints to keep the clients in bed all night
- Restraints can prevent clients from harming themselves
- If we apply restraints, a client can't pull out their Foley catheter
Correct answer: We put on the restraints to keep the clients in bed all night
Wrist or ankle restraints are used only to limit movement, to prevent harm to the client or others, or to prevent a client from pulling out catheters, tubes, or lines. Restraints are never used to punish a client or for the convenience of the staff. A prescription for restraints must be obtained from the client's primary provider.
- A newly admitted patient has an arteriovenous (AV) fistula for hemodialysis in the left arm. What should the nurse do to prevent injury to the fistula?
- Place a large sign above the patient's bed
- Instruct the patient to inform all staff
- Put an alert bracelet on the patient's left arm
- Make a note in the patient's health record
Correct answer: Put an alert bracelet on the patient's left arm
An AV fistula is necessary for performing hemodialysis. There should be no blood pressure readings or venipunctures in the arm with the fistula. An alert bracelet will notify anyone regardless of whether the patient is alert or where the patient is. Signs and notes in the health record may not be seen by everyone. The patient is not responsible for informing the staff.
- The entire staff attends a mandatory inservice on the use of anthrax in bioterrorism. Which statement by a staff member indicates the need for further instruction?
- Anthrax produces a neurotoxin that causes paralysis
- Inhaling anthrax spores can be lethal
- Anthrax can be treated with antibiotics
- Anthrax can be transmitted by eating contaminated meat
Correct answer: Anthrax produces a neurotoxin that causes paralysis
Anthrax is an infection caused by the bacterium Bacillus anthracis. It can be spread by direct or indirect contact with sick hooved animals. It is transmitted by inhalation or skin wounds or through the digestive system. Botulism, caused by a neurotoxin from the bacterium Clostridium botulinum, causes paralysis, which can be fatal.
- The nurse checks a client’s chart for drug allergies before administering an injection of penicillin. The chart states "NKA." She attempts to verify this with the client before giving the injection. The client says that he had a rash after receiving another shot, but he can't recall the medication. What is the nurse's best action?
- Hold the penicillin and notify the physician who ordered the drug
- Contact the pharmacy to learn whether penicillin reactions include a rash
- Administer the penicillin injection and document the client's remark
- Notify the nursing supervisor of the error in the client's record
Correct answer: Hold the penicillin and notify the physician who ordered the drug
Do not administer penicillin if there is a possibility of it causing an allergic reaction. Notify the physician instead. Common adverse reactions to penicillin include nausea, rash, hives, itching, and swelling of the face, lips, and tongue. Anaphylaxis can occur within 60 minutes. The nurse should always check the client record, and whenever possible, ask the client before giving a medication.
- The pediatric nurse is preparing to administer a medication to a 3-year-old patient. Besides checking the child's arm band, the nurse should also
- Ask a parent to identify the child
- Ask the parent to step out of the room
- Ask the child to state their name
- Ask the child to state their age
Correct answer: Ask a parent to identify the child
Young children are at risk for medication errors, because they can't communicate. They may not know their full name, or they may be accustomed to being called by a nickname that is not on the ID band. Knowing how old they are is not adequate; birth dates are required. Parents may be used as the second source of identification. Parents are not asked to leave their child; in some hospitals, the nurse can allow the parent to administer the medication to the child.
- While setting up to do a sterile dressing change, the nurse places sterile 4 x 4 gauze pads on the sterile field, but then the nurse accidentally touches the field with an ungloved hand. Which action should the nurse take?
- Fold over the area of the field that was touched and continue
- Put on fresh sterile gloves and replace the gauze pads
- Replace the gauze pads that were on top
- Discard the field and gauze pads and start over
Correct answer: Discard the field and gauze pads and start over
If a sterile field becomes contaminated, everything must be replaced. When setting up a sterile field, the area must be clean and dry. The nurse uses clean gloves to remove the old dressing and sterile gloves to apply the new dressing. The other options are absolutely incorrect.
- As the nurse prepares to administer ampicillin 500 mg PO to a post-op patient, he checks the capsule in the patient's medication box. The dosage of the capsule is not labeled, but the nurse is familiar with the color and shape. The nurse should
- Ask a second nurse to verify the medication is ampicillin
- Contact the nursing supervisor to report the error
- Give the patient the capsule to maintain the schedule and blood level
- Call the pharmacy to bring properly labeled medication
Correct answer: Call the pharmacy to bring properly labeled medication
The nurse should never administer a medication that is not properly labeled, even if the nurse (or another nurse) recognizes it. The nurse should call the pharmacy to deliver a properly labeled medication. The nurse can handle the situation without contacting a supervisor.
- The nurse is assessing a patient who is recovering from a recent stroke. Which of these problems is the FIRST priority?
- Impaired mobility
- Impaired communication
- Risk of altered coping
- Risk of aspiration
Correct answer: Risk of aspiration
"ABC" stands for "Airway, Breathing, Circulation." For every patient, these are the priority. For this patient, the first problem to address is the possibility of aspirating and choking. The other problems can be taken care of after the airway and breathing are secure.
- Which of the following is the second period or stage of the infection process?
- Incubation
- Decline
- Prodromal
- Illness
Correct answer: Prodromal
After the initial entry of the pathogen into the host, the first period of infection is incubation, when the pathogen begins to multiply. The prodromal period is when the host begins to display signs and symptoms and the immune system activates. The period of illness occurs when signs and symptoms are most obvious and severe. The period of decline is when the number of pathogens decreases and signs and symptoms resolve. During the final period of convalescence, the body returns to normal.
- The nurse in the birthing and maternity unit is training new unlicensed assistive personnel (UAP) on standard precautions. Which of the following observations by the nurse would indicate the need for further instruction?
- The UAP disposes of needles in a designated sharps container
- The UAP uses sterile gloves to bathe a neonate who is 4 hours old
- The UAP wears clean gloves to help the mother change her peri-pad
- The UAP places soiled sheets in a marked container for contaminated linens
Correct answer: The UAP uses sterile gloves to bathe a neonate who is 4 hours old
There is no need to wear sterile gloves to bathe a neonate. Clean gloves are sufficient. Sterile gloves are expensive and unnecessary. The other options are appropriate actions for taking standard precautions.
- A client is being admitted to the unit with a diagnosis of rule-out Laennec's cirrhosis of the liver. During the initial assessment, the nurse observes that the client is constantly scratching their skin. The nurse knows that this pruritus is the result of
- A buildup of ascitic fluid
- Elevated cholesterol levels
- Reduced phagocyte activity
- Accumulation of bile salts
Correct answer: Accumulation of bile salts
Laennec's, or portal, cirrhosis is primarily caused by excessive and chronic alcohol consumption. The relationship between alcohol and cirrhosis is unquestioned, but the mechanism of injury remains unknown. Itching (pruritus) is caused by the buildup of bile salts related to faulty processing of bilirubin. If bilirubin levels are high, substances formed when bile is broken down may accumulate. Reduced or loss of phagocytic activity leads to infection and possibly bacterial peritonitis. Ascites is caused by liver scarring, which increases pressure in the liver's blood vessels and forces fluid out. Although the liver produces cholesterol, this is not the cause of the client's pruritus.
- During new employee orientation, the nurse provides information about exposure to bloodborne pathogens and the risk of human immunodeficiency virus (HIV) transmission. Which statement by the nurse is MOST important?
- Treatment for exposure may include antiretroviral medications
- Report any possible exposure of HIV-containing fluids immediately
- Transmission of HIV from clients to health care workers is rare
- HIV testing after exposure is done at specific intervals
Correct answer: Report any possible exposure of HIV-containing fluids immediately
Possible exposure to HIV-containing fluids should be reported immediately. According to the Centers for Disease Control and Prevention (CDC), after exposure to HIV, prophylactic treatment with antiretrovirals should be started as soon as possible. Optimally, treatment begins within hours of exposure. The other statements are true, but not the most important for educating new employees.
- Which of the following is an early symptom of gonorrhea in males?
- Urethral discharge
- Penile lesion
- Watery stools
- Erectile dysfunction
Correct answer: Urethral discharge
Gonorrhea is an infection caused by the bacterium Neisseria gonorrhoeae. The symptoms of gonorrhea generally appear within 7-10 days after exposure. In males, one of the early symptoms of gonorrhea is a profuse, purulent discharge from the penis. Other symptoms are a burning sensation when urinating, increased urgency and frequency of urination, swelling or redness at the urinary meatus, and pain or swelling of the testicles. The other answer options are not related to gonorrhea.
- Before a nurse implements a bladder retraining program for an incontinent client, what is the FIRST action that the nurse should take?
- Place a commode at the bedside
- Gather data on the client's voiding pattern
- Limit the client's daily fluid intake
- Schedule regular times for urination
Correct answer: Gather data on the client's voiding pattern
The first step in starting a bladder training program is to learn the client's current voiding pattern so that the nurse can plan a personalized schedule for the client. Limiting fluids will cause urine to be concentrated and can lead to a fluid deficit. Obtaining a commode may be appropriate, but it should be done only after assessing the client's voiding pattern.
- A pediatric patient has been diagnosed with right lower lobe pneumonia. Upon auscultation of this lung field, the healthcare provider should expect to hear which breath sounds?
- Crackles
- Rhonchi
- Stridor
- Wheezes
Correct answer: Crackles
Crackles would most likely be heard because they indicate fluid in the airspace. Fluid in the airspace is consistent with pneumonia. Wheezes indicate a narrowing of the airways. Stridor is an emergency lung sound that is seen in airway constriction that can lead to complete closure. Rhonchi are heard in mixed-issue airway constriction and secretions.
- A 10-year-old boy is admitted to the pediatric unit with a diagnosis of viral meningitis. He is experiencing a severe headache, a stiff neck, vomiting, photophobia, and drowsiness. The nurse can make him more comfortable by
- Providing him with a large, soft pillow
- Encouraging him to drink fluids
- Teaching him deep breathing
- Closing the shades and dimming the lights
Correct answer: Closing the shades and dimming the lights
The first action should be to alleviate the photophobia by darkening the room. This may alleviate the child's headache also. Deep breathing can be useful but will not eliminate the discomfort of meningitis symptoms. Fluid balance is important but not the first priority. A large, soft pillow may place the neck in an awkward position and exacerbate the child's discomfort by stretching the meninges.
- A client with chronic renal failure (CRF) is learning to perform peritoneal dialysis at home. The nurse instructs the client to warm the dialyzing solution to 37 degrees Celsius so that it will
- Remove toxins from the body's cells
- Relax the abdominal muscles
- Dilate the peritoneal blood vessels
- Maintain a constant body temperature
Correct answer: Dilate the peritoneal blood vessels
The rationale for warming the peritoneal dialysis solution is that the warm solution helps dilate peritoneal vessels, which increases urea clearance. Warmed dialyzing solution also contributes to client comfort by preventing cold sensations, but this is a secondary reason for warming the solution. The other options are incorrect
- A client with end-stage renal disease has opted for an arteriovenous (AV) fistula for long-term treatment with hemodialysis. Following the surgical creation of the AV fistula, when will the client be able to use it for hemodialysis?
- 2-3 months
- 4–6 weeks
- 4-6 months
- 2-3 weeks
Correct answer: 2-3 months
An AV fistula is a connection of an artery to a vein, created by a vascular surgeon. An AV fistula frequently requires 2 to 3 months to develop or mature before the patient can use it for long-term hemodialysis.
- The purpose of a splint is to
- Immobilize and allow for tissue swelling
- Wrap around an injury for full protection
- Provide permanent support for a fracture
- Manage complex or unstable fractures
Correct answer: Immobilize and allow for tissue swelling
The primary purposes of splinting for limb fractures are to protect soft tissue from further damage, allow for tissue swelling, reduce the client's pain, reduce the possibility of a fat embolism, and minimize painful muscular spasms. A splint is easily applied and removed and involves fewer complications than a cast. A cast is indicated for total immobilzation, to wrap completely around the fracture or injury, and to manage complex or unstable fractures.
- After emptying a Jackson-Pratt drainage bulb, how does the nurse reestablish negative pressure in the system?
- Fill the bulb with sterile saline solution.
- Place the bulb lower than the client's body.
- Compress the bulb and close the valve.
- Open the valve and fill the bulb with air.
Correct answer: Compress the bulb and close the valve.
A Jackson-Pratt drain creates negative pressure when the bulb is compressed and the valve is closed. This causes fluid around the surgical site to flow into the drain.
- A female patient complains of abdominal discomfort. Watery stool has been leaking from her rectum. This could be a sign of
- Bowel incontinence
- Diarrhea
- Fecal impaction
- Constipation
Correct answer: Fecal impaction
Fecal impaction can be serious. When constipation is not resolved, stool becomes hardened and unable to pass. Liquid stool may pass around the impaction. Patients may complain of feeling bloated; having the urge to push; nausea or vomiting; or not wanting to eat. The impaction may need to be manually removed. Patient education should include increasing liquids and fiber, as well as regular physical activity.
- A client receives a new order for levothyroxine (Synthroid) 150 mcg PO every day. The pharmacy sends Synthroid 0.1 mg tablets. How many tablets will the nurse administer?
- 1.5 tablets
- 1.0 tablet
- 2 tablets
- .5 tablet
Correct answer: 1.5 tablets
1. Convert mcg to mg: 150 mcg÷1000=0.15 mg Synthroid. 2. Calculate and solve: 0.1 mg0.15 mg×1 tablet=1.5 tablets (121 tablets).
- 76 parts per 100 may be written as all of the following EXCEPT
Correct answer: 100/76
Percent means per 100. To express 76 parts per 100 in different formats: 1. Divide 76 by 100 = 0.76; 2. Use the percentage symbol (76%); 3. Write as a fraction (76/100). Dividing 100 by 76 is incorrect.
- The health care provider (HCP). prescribes acetaminophen gr VIII PO PRN for headache pain. The client has 500 mg caplets. How many caplets should the client take?
- 2 caplets
- 3 caplets
- 4 caplets
- 1 caplet
Correct answer: 1 caplet
The client should take one caplet. 1 grain = 64.8 mg. 8×64.8=518.4 mg. This is the closest dosage to the prescription. A grain is a unit of mass and an obsolete measurement in pharmacology. It is still sometimes used for older medications, such as aspirin, codeine, or phenobarbital.
- The health care provider (HCP) prescribes heparin 6,789 units subcutaneously q 12 hr. The nurse has a vial of heparin with 10,000 units/mL. How many mL will the nurse draw up and administer? Round the answer to one decimal place.
Correct answer: 0.7 mL
The nurse will administer 0.7 mL of heparin. To calculate: use the (desired dose × vehicle amount) ÷ (amount on hand) formula. For this question: 1. Divide 6,789 units (desired dose) by 10,000 units (available dose): 10,0006,789=0.6789. 2. Multiply by 1 mL (vehicle): 0.6789×1 mL=0.6789 mL. 3. Round to one decimal place: 0.7 mL.
- The nurse is instructing a client about a newly prescribed medication, furosemide (Lasix). Which adverse effect should the nurse discuss?
- Dry mouth
- Leg cramps
- Poor appetite
- Increased energy
Correct answer: Dry mouth
Furosemide (Lasix) is a diuretic that slows the absorption of sodium and chloride in the kidney, resulting in increased water and urine output. The reduction of body fluid may result in dry mouth. Appetite and energy are not affected by furosemide. Leg cramps result from low potassium (hypokalemia).
- A patient who is receiving a unit of blood complains of chills and dizziness. The nurse observes that the patient is dyspneic and the patient's face appears flushed. The nurse immediately notifies the RN. What is the likely cause of these symptoms?
- Air embolism
- Bacterial sepsis
- Fluid overload
- Transfusion reaction
Correct answer: Transfusion reaction
A transfusion reaction can be an allergic response of the recipient to the donor's blood. If a reaction is suspected, the transfusion must be stopped immediately. Blood samples are drawn, and the unit of blood is returned to the blood bank for further testing. Symptoms of a transfusion reaction usually occur during or right after the transfusion, but they can sometimes be delayed for several days.
- A resident has a flare-up of psoriasis, so the physician orders salicylic acid foam to be applied topically. The nurse knows to watch for which sign of systemic toxicity?
- Photophobia
- Diarrhea
- Tinnitus
- Seizures
Correct answer: Tinnitus
Salicylic acid is easily absorbed by the skin. It is in the same family as aspirin (acetylsalicylic acid). For both salicylic acid and aspirin, one of the earliest signs of systemic toxicity is tinnitus, or ringing in the ears. The other answer options are not related to the administration of salicylic acid.
- A patient receives a new order for levothyroxine (Synthroid) 150 mcg PO every day. The pharmacy sends Synthroid 0.1 mg tablets. How many tablets will the nurse administer?
- 1.0 tablet
- 2 tablets
- 0.5 tablet
- 1.5 tablets
Correct answer: 1.5 tablets
1. Convert mcg to mg: 150 mcg÷1000=0.15 mg Synthroid. 2. Calculate and solve: 0.1 mg0.15 mg×1 tablet=1.5 tablets (121 tablets).
- The health care provider (HCP) prescribes acetaminophen liquid 160 mg PO q 4-6 hr PRN for a child with a fever. Pharmacy dispenses 80 mg/mL. How many mL should the nurse administer for a dose?
Correct answer: 2 mL
A dose of 160 mg of acetaminophen is 2 mL. To calculate: use the (desired dose × vehicle amount) ÷ (amount on hand) formula. For this question: 80 mg160 mg×1 mL=2 mL.
- The health care provider (HCP). prescribes a keep vein open (KVO) rate of 10 mL/hr at 0800. There are 135 mL remaining in a bag of 0.9% NS. What time will the bag of solution be infused?
- 2330 (11:30 pm)
- 2030 (8:30 pm)
- 2130 (9:30 pm)
- 2230 (10:30 pm)
Correct answer: 2130 (9:30 pm)
The remaining solution should be completely infused at 2130 (9:30 pm). To calculate: 1. Divide 135 mL by the rate of 10 mL/hr: 10 mL/hr135 mL=13.5 hr. 2. Add 13.5 hr to 0800, when the order was written, to reach 2130 (9:30 pm). 3. You can also count ahead 13.5 hr to reach 2130 (9:30 pm). "Keep vein open" (KVO) is a medical acronym for an intravenous drip that is flowing just enough to keep the IV open for possible future use. It is also sometimes written as TKO, "to keep open."
- The provider orders furosemide (Lasix) oral solution 0.5 mL stat. Pharmacy sends a bottle marked 10 mg/mL. What dosage will the nurse administer?
Correct answer: 5 mg
The concentration is 10 mg/mL, so 0.5 mL×10 mg/mL=5 mg.
- The health care provider (HCP) prescribes 1/2 strength tube-feeding formula for a client who is restarting enteral nutrition. A standard can of formula contains 240 mL. How much water should the nurse add to obtain 1/2 strength?
Correct answer: 240 mL
The nurse will add 240 mL of water. The V1C1=V2C2 formula is used to calculate dilutions. V1 = volume of starting solution; C1 = concentration of starting solution; V2 = final volume of new solution; C2 = final concentration of new solution. For this question: V1=240 mL, C1=1.0 (100%), C2=0.50 (50%). Solve for V2: V2=0.50240 mL×1.0=480 mL (final total volume). NOTE: total volume − starting volume = diluent volume (480 mL−240 mL=240 mL).
- A client receiving hemodialysis therapy weighs 78 kg today. The nurse notes that the client's previous weight was 76 kg. What is the percent change? Round to two decimal places.
Correct answer: 2.63%
To calculate a percent change, use this formula: InitialFinal−Initial×100%. For this question: 1. 78 kg−76 kg=2 kg. 2. 76 kg2 kg=0.0263. 3. 0.0263×100%=2.63%.
- The nurse is encouraging a client to increase their daily fluid intake to 2 liters. The client asks, "How much is that?" The nurse then tells the client to drink how many 8-ounce glasses of liquids each day? Round to the nearest whole.
- 12 glasses
- 6 glasses
- 10 glasses
- 8 glasses
Correct answer: 8 glasses
To calculate: 1. Convert 2 liters to mL: 2 L=2000 mL. 2. Divide the mL by 30 to find how many ounces: 302000=66.66 ounces. 3. Divide by 8 to determine how many 8-ounce glasses the client should drink each day: 866.66=8.33. 4. The client should drink 8 glasses of fluid each day.
- A client has been taking a warfarin 5 mg tablet every day. Following a routine international normalized ratio (INR) test, the health care provider (HCP) increases the client's dose to 7.5 mg PO daily. How many (scored) tablets should the nurse instruct the client to take each day?
- 3 tablets
- 2 tablets
- 1.5 tablets
- 2.5 tablets
Correct answer: 1.5 tablets
The client will take 1.5 tablets every day. To calculate: divide the desired dose by the dose on hand (or available). For this question: 5 mg7.5 mg=1.5 tablets. A second way to calculate: 1. Known: 1 tablet = 5 mg. 2. Unknown: ? tablets = 7.5 mg. 3. Set up an equation: 7.5 mg×5 mg1 tablet=1.5 tablets.
- The provider orders "gabapentin 18 mg/kg/day in 3 divided doses" for a child who weighs 28 kg. How many mg will the nurse administer for each dose?
Correct answer: 168 mg
Answer: 168 mg each dose. To calculate: 28 kg×18 mg/kg/day=504 mg total dosage each day. 3504 mg=168 mg per dose.
- The pediatrician orders cephalexin monohydrate 0.5 g PO q8 hrs for a child with a diagnosis of pneumonia. The pharmacy sends the medication with 500 mg per teaspoon. How many mL should the nurse administer?
Correct answer: 5 mL
To calculate the correct dose, first convert to equivalent units: 1 g = 1,000 mg; 1 tsp = 5 mL. For this question: 0.5 g×1 g1000 mg=500 mg. The nurse will administer 5 mL (1 teaspoon).
- When a nurse collects a stool sample to be tested for ova and parasites, which nursing action is correct?
- Delivering the stool sample directly to the laboratory
- Ensuring that the sample is sent to the laboratory in a sterile container
- Holding the specimen container in contact with the anus
- Refrigerating the specimen to maintain viability
Correct answer: Delivering the stool sample directly to the laboratory
Stool that is to be tested must be examined while the specimen is fresh and warm. Ova and parasites will not survive below body temperature. The feces can be collected with a tongue blade from a bedpan or the toilet, and then placed in a nonsterile covered container.
- The nurse is assessing a patient recovering from a total knee replacement. Which of these assessment findings indicates the patient is at risk of developing a complication from the surgery?
- Incision site edema
- Homans' sign negative
- Hemoglobin 12.5 g/dL
- Pale toenail beds
Correct answer: Pale toenail beds
Pale nailbeds of the toes indicate neurovascular damage. Other signs of neurovascular dysfunction in an extremity include diminished or absent pedal pulses; capillary refill in toes > 3 seconds; inability to flex or extend the knee, foot, or toes; and numbness or tingling in the foot. Edema should be monitored but is an expected finding during the initial recovery period. A negative Homans' sign is part of an expected assessment finding if the patient is not experiencing a deep vein thrombosis. The patient's hemoglobin is within the normal range of 13.5-17.5 gm/dL for males and 12.0-15.5 gm/dL for females.
- After an 86-year-old female resident falls and breaks a hip at a long-term care facility, the nurse reviews the resident's chart. Which condition MOST predisposes the resident to a fracture?
- She has had Type 2 diabetes for 15 years
- She has been lactose intolerant since age 19
- She is 36 years postmenopausal
- She is obese, with a BMI of 30.2
Correct answer: She is 36 years postmenopausal
After menopause, estrogen levels drop, resulting in a loss of calcium from the bones. When bone mass is reduced, the entire skeletal structure can be jeopardized and the risk of fractures increases. Obesity puts stress on the skeleton but doesn't necessarily predispose it to fractures. Type 2 diabetes is not a risk factor. Lactose intolerance means that some dairy products can cause intestinal distress, but calcium can be obtained from other sources.
- The results of a patient's latest arterial blood gas (ABG) test are as follows: pH 7.5, PaCO2 30 mmHg. What acid-base imbalance do these results indicate?
- Respiratory acidosis
- Metabolic alkalosis
- Respiratory alkalosis
- Metabolic acidosis
Correct answer: Respiratory alkalosis
Normal values for ABG results are pH 7.35-7.45 and PaCo2 3545 mmHg. A high pH and low PaCo2 indicate respiratory alkalosis. The main cause of respiratory alkalosis is tachypnea, or hyperventilation. To correct the alkalosis, the client can slow their breathing, hold their breath, or breathe into a paper bag or rebreather mask.
- A physician orders 2 units of packed RBCs for a client with a diagnosis of severe anemia. The most important nursing action for administering the blood product is
- To use an 18-gauge needle for the blood infusion
- To verify the blood product with another RN
- To transfuse both units of blood within two hours
- To place the signed consent in the medical record
Correct answer: To verify the blood product with another RN
Avoiding a transfusion error is the first priority. The nurse should verify all client and blood information with another RN before starting the infusion. An 18-gauge needle is appropriate. A signed consent is required, but placing it in the client's medical record is not the most important nursing action. The ordering provider determines the amount of time for the transfusion.
- During a Code Blue, a resident attempts to intubate the patient with an 8 mm endotracheal tube (ETT). As the nurse auscultates the patient's chest afterwards, breath sounds are absent on the left side. What is the most likely cause of this?
- Right bronchus intubation
- Aspiration
- Left pneumothorax
- Wrong ETT size
Correct answer: Right bronchus intubation
During intubation, the right mainstem bronchus can be inadvertently entered if the endotracheal tube is inserted too far. Adult endotracheal tube (ETT) sizes are 7.0–8.5 mm. While pneumothorax could result in absence of breath sounds, the possibility of tube position should be considered first. Aspiration would not result in absence of breath sounds.
- The nurse working on a cardiac unit receives a prescription for a 20 mEq potassium chloride KCl IV piggyback. Which ECG finding on the client's monitor will cause the nurse to notify the health care provider (HCP) before administering the KCl?
- Peaked T waves
- Short PR interval
- Narrow QRS complex
- Prominent U waves
Correct answer: Peaked T waves
Tall, peaked T waves with a narrow base are early indications of hyperkalemia, so administering more potassium is not recommended. The normal serum potassium range is 3.5-5.0 mmol/L. Hyperkalemia occurs when the serum level exceeds 5.5 mmol/L. A level about 6.5 mmol/L requires immediate medical intervention. Prominent U waves are characteristic of hypokalemia. A short PR interval is seen when the AV node delay is bypassed, as in Wolff-Parkinson-White syndrome. A narrow QRS complex is consistent with sinus tachycardia.
- The healthcare provider is reviewing the laboratory reports of a patient admitted to the medical unit for observation. Which of these assessment findings requires immediate intervention?
- Serum potassium level of 4.5 mEq/L (4.5 mmol/L)
- An International Normalized Ratio (INR) of 0.9
- Serum magnesium level of 3.5 mEq/L (1.75 mmol/L)
- Blood urea nitrogen (BUN) level of 28 mg/dL (99.9 mmol/L)
Correct answer: Serum magnesium level of 3.5 mEq/L (1.75 mmol/L)
The magnesium level is elevated. Normal range is 1.5-2.5 mEq/L. Consequences of elevated magnesium include respiratory depression and heart block. Hypermagnesemia will have the most serious consequences. The BUN level is also elevated. Normal range is 7-22 mmol/L. The patient will need an evaluation, but this is not as critical as treating the hypermagnesemia. The potassium level is within the normal range of 3.5-5.0 mEq/L. The INR is within the normal range of 1.1 or lower
- The healthcare provider prepares to administer a pneumococcal vaccine to a 65-year-old patient who has a diagnosis of chronic bronchitis. The patient states, "I got that vaccine 5 years ago." What is the most appropriate response by the healthcare provider?
- This vaccination is given every other year to anyone with lung disease.
- We can give you a flu shot instead of a pneumococcal vaccination.
- You will need this vaccination annually, just like the flu shot.
- Your last shot was when you were 60, so a repeat vaccination is recommended.
Correct answer: Your last shot was when you were 60, so a repeat vaccination is recommended.
To help prevent pneumonia and its complications, an additional pneumococcal dose is recommended for adults who first received the vaccine before age 65. Under current CDC/ACIP guidance (updated 2024), a high-risk adult under 65 with a chronic condition such as chronic bronchitis may receive an earlier pneumococcal dose; a repeat dose with a higher-valent conjugate vaccine (PCV20 or PCV21) is then recommended at or after age 65 to broaden serotype coverage. The exact product and interval are determined by what the patient previously received, so the provider confirms the prior dose was given before 65 and that a repeat is now appropriate.
- A patient who takes daily low-dose aspirin experiences prolonged bleeding from a superficial cut. Which of the following lab results would be expected for this patient?
- Activated partial thromboplastin time (aPTT) 30 seconds
- Prothrombin time (PT) 14 seconds
- Platelets 150×109/L
- Bleeding time of 8 minutes
Correct answer: Bleeding time of 8 minutes
During primary hemostasis, a platelet plug is formed. Clotting factors are involved in secondary hemostasis (coagulation). Both aPTT and PT measure the coagulation pathways. Aspirin inhibits cyclooxygenase (COX), which promotes the synthesis of TXA2. Because TXA2 is necessary for platelet aggregation, primary hemostasis is inhibited. This is measured by bleeding time. Platelet activity is affected but not the number of platelets.
- A client with a known diagnosis of type 1 diabetes presents to the Emergency Department with a blood glucose level of 538 mg/dL. The nurse knows that the client is at the greatest risk for which acid-base imbalance?
- Respiratory alkalosis
- Metabolic acidosis
- Respiratory acidosis
- Metabolic alkalosis
Correct answer: Metabolic acidosis
The client is at the greatest risk of developing metabolic acidosis. Diabetic ketoacidosis is defined as an increase in the serum concentration of ketones greater than 5 mEq/L, a blood sugar level greater than 250 mg/dL (although it is usually much higher), and a blood (usually arterial) pH less than 7.3. Because of insufficient insulin, glucose continues to circulate while the body uses fat and glycogen for energy. Byproducts of fat metabolism (ketones) are acidic, leading to metabolic acidosis.
- A patient presents to the emergency department with a blood pressure of 180/130 mmHg, headache, and confusion. Which additional finding is consistent with a diagnosis of hypertensive emergency?
- Bradycardia
- Urinary retention
- Retinopathy
- Jaundice
Correct answer: Retinopathy
A hypertensive emergency is a sudden rise in blood pressure, with a reading of 180/120 mmHg or higher. Immediate intervention is necessary. A hypertensive emergency may cause hypertensive retinopathy, resulting in hemorrhages, exudates, or papilledema. Other consequences of a hypertensive emergency include stroke, heart attack, aortic dissection, kidney damage, and pulmonary edema.
- A patient with a diagnosis of WolffParkinson-White syndrome is undergoing a catheter ablation procedure. For the healthcare provider caring for the patient after the procedure, which is the priority intervention?
- Assist the patient to the bathroom to void.
- Auscultate apical pulse for a full minute every hour
- Assess level of consciousness every 20 minutes
- Monitor insertion site and distal pulses
Correct answer: Monitor insertion site and distal pulses
Because the catheter may cause trauma to the vessels, the healthcare provider will monitor for hematoma formation and interference of circulation distal to the insertion site. Bleeding at the site is the most common complication. Assessing level of consciousness is a routine post-op order, so it is not a priority. The extremity where the catheter was inserted will be immobilized initially, so the patient will not be allowed out of bed to use the bathroom. The patient will be on a cardiac monitor, so auscultation of the apical pulse for one minute is not a priority.
- A client with a diagnosis of possible appendicitis is a direct admit from the clinic. The nurse knows that a positive sign of appendicitis is
- Chadwick's
- Homans'
- Psoas
- Murphy's
Correct answer: Psoas
A positive Psoas sign indicates the presence of inflammation of the psoas muscle. A positive Murphy's sign indicates cholecystitis. A positive Homans' sign is related to a deep vein thrombosis in a leg. A positive Chadwick's sign is normal during pregnancy.
- Following application of a short leg cast for a fractured ankle, which discharge instruction by the nurse is correct?
- You can cut and smooth the edges of the cast once it has dried
- Use pillows to elevate the cast above your heart for 24 hours
- Burning and tingling sensations under the cast are normal
- Start walking on the cast as soon as it dries so you can adapt
Correct answer: Use pillows to elevate the cast above your heart for 24 hours
Elevating the leg is the best discharge instruction. Decreasing edema, which can lead to compartment syndrome, is the priority after a cast is applied. Cutting the cast can cause fragments to fall into the cast and cause skin irritation; instead, clients should be instructed to "petal" the edges. Walking or weight bearing is usually not permitted until a follow-up visit. Burning and tingling are abnormal signs, indicating nerve damage or ischemia.
- A nurse in the Emergency Department assesses a client for a possible fractured rib. Which of the following characteristics will support the suspected diagnosis?
- Pain on inspiration, with deep, rapid respirations
- Pain on inspiration, with shallow, guarded respirations
- Pain on expiration, with deep, rapid respirations
- Pain on expiration, with shallow, guarded respirations
Correct answer: Pain on inspiration, with shallow, guarded respirations
A client with a fractured rib will complain of pain on inspiration or when moving or coughing. There will also be pain when the site is palpated. Respirations will be shallow and guarded; it will be nearly impossible for the client to take a deep breath. There may also be shortness of breath as well as bruising at the site.
- When assessing a patient diagnosed with osteoarthritis (OA), the healthcare provider looks for which characteristic of this condition?
- Joint crepitus
- Bilateral joint swelling
- Waddling gait
- Decreased grip strength
Correct answer: Joint crepitus
Crepitus, also called crepitation, describes the grinding, grating, creaking, or popping sounds that occur when a joint moves. Crepitus is present when cartilage is lost. It is characterized by a popping, grating sound. Alternatively, sometimes the patient feels bone rubbing against bone, secondary to loss of cartilage. Decreased grip strength and bilateral joint swelling are more often seen in rheumatoid arthritis. A waddling gait (a duck-like gait) is sometimes seen in the third trimester of pregnancy (caused by anatomical and hormonal changes) or with muscular diseases such as muscular dystrophy.
- A client complains of a stabbing pain on one side of the face. The nurse suspects tic douloureux, which is caused by which cranial nerve?
Correct answer: V
Tic douloureux (also known as trigeminal neuralgia) is a chronic pain condition, stemming from one or more of the three branches of the trigeminal nerve (the fifth cranial nerve). This condition is characterized by a sudden, severe, stabbing pain on one side of the face, and is considered one of the most painful conditions to afflict humans.
- The healthcare provider is caring for a patient on a ventilator with an endotracheal tube in place. What assessment data indicate the tube has migrated too far down the trachea?
- Increased crackles auscultation bilaterally
- Low-pressure alarm sounds
- High-pressure alarm sounds
- Decreased breath sounds on the left side of the chest
Correct answer: Decreased breath sounds on the left side of the chest
If the endotracheal tube is inserted too far, it will often go into the right main stem bronchus. Then air will be delivered to the right lung but not the left. A low-pressure alarm indicates a disconnection or a leak in the circuit. A high-pressure alarm can mean an obstruction, such as a kink in the tubing or a need for suctioning
- What is the safest method of changing a patient's tracheostomy ties?
- Ask the doctor to suture the tracheostomy in place
- Apply the new ties before removing the old ones
- Never attempt to change ties alone
- Change ties as soon as possible after the patient has eaten
Correct answer: Apply the new ties before removing the old ones
The best way to change tracheostomy ties is to apply the new ties before removing the old ones. This keeps the tracheostomy in place during the process. With this method, a second person is not necessary; besides, a helper might not prevent the patient from coughing out the tracheotomy. To prevent the patient from vomiting, wait two hours after the patient has eaten before you change the ties. Asking the doctor to suture the tracheostomy in place is not appropriate.
- Which of these assessment findings should the healthcare provider expect to identify as an early clinical characteristic of multiple sclerosis (MS)?
- Dementia
- Clonus
- Vision loss
- Muscle atrophy
Correct answer: Clonus
Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system. Demyelination will cause slowed conduction and eventually loss of function. Vision loss and eye pain (optic neuritis) are early symptoms of MS, caused by inflammation of the optic nerve. Dementia is uncommon and found only in severely affected patients. Clonus (rhythmic contractions when a muscle is stretched) is a sign of nerve damage, which may be seen as MS progresses. Muscle atrophy is also a later sign of MS, which is caused by disuse of a muscle group.
- A client with a history of chronic cirrhosis of the liver was admitted two days ago to treat an infection. Today, during the initial shift assessment, the nurse notes that the client appears lethargic and their breath has a sweet, musty odor. Which assessment should the nurse perform NEXT?
- Obtain a full set of vital signs
- Review recent serum bilirubin result
- Measure client's abdominal girth
- Observe for flapping hand tremors
Correct answer: Observe for flapping hand tremors
In patients with chronic liver disease, acute episodes of encephalopathy are usually precipitated by reversible causes. The most common are the following: Metabolic stress (e.g., infection; electrolyte imbalance, especially hypokalemia; dehydration; use of diuretic drugs) and Nonspecific cerebral depressants (e.g., alcohol, sedatives, analgesics). Symptoms usually do not become apparent until brain function is moderately impaired. A musty, sweet breath odor (fetor hepaticus) can occur regardless of the stage of encephalopathy. Asterixis is a characteristic flapping tremor that is elicited when patients hold their arms outstretched with wrists dorsiflexed. Elevated bilirubin would cause jaundice. Vital signs are already part of an initial assessment.
- Scopolamine and atropine are two examples of anticholinergic medications. All of the following are frequent side effects of anticholinergic drugs EXCEPT
- Urinary retention
- Cognitive changes
- Pupil constriction
- Dry mouth
Correct answer: Pupil constriction
Anticholinergics are drugs that block the binding action of the neurotransmitter acetylcholine. They inhibit parasympathetic nerve impulses. Common side effects include dry mouth, urinary retention, blurred vision, constipation, dizziness, pupil dilation, and cognitive changes. Anticholinergic drugs include some antihistamines, tricyclic antidepressants, medications to control an overactive bladder, and drugs to relieve the symptoms of Parkinson's disease.
- Which atrioventricular (AV) heart block is called Mobitz II?
- First-degree AV heart block
- Third-degree AV heart block
- Second-degree AV heart block
- Complete AV heart block
Correct answer: Second-degree AV heart block
Second-degree heart block Type 2, which is also called Mobitz II or Hay, is a disease of the electrical conduction system of the heart. Second-degree AV block (Type 2) is almost always a disease of the distal conduction system located in the ventricular portion of the myocardium. The rhythm can be identified by (1) nonconducted P waves (electrical impulse conducts through the AV node but complete conduction through the ventricles is blocked, thus no QRS); (2) P waves are not preceded by PR prolongation as with second-degree AV block Type 1; (3) fixed PR interval; (4) the QRS complex will likely be wide.
- A client with a known history of asthma comes to the surgicenter for a minor procedure. The nurse measures the client's pre-procedure peak flow at 520 liters/minute. Following the procedure, the client complains of "a tight chest" and their peak flow is 250 liters/minute. What is the nurse's PRIORITY action?
- Notify the health care provider (HCP)
- Repeat the peak flow reading in 15 minutes
- Apply oxygen at 2LPM via nasal cannula
- Administer a PRN dose of albuterol
Correct answer: Administer a PRN dose of albuterol
A peak flow reading of less than 50% of the client's baseline reading is a medical alert condition and a short-acting beta agonist must be taken immediately. Normal adult peak flow is 400-700 liters/minute. For clients with asthma, 80-100% of "personal best" indicates that asthma is controlled. Peak flow of 50-80% means asthma is not controlled or worsening. Less than 50% is a medical emergency Notifying the HCP is important, but can be done after administering the PRN dose. O2 therapy will not help until the airway is no longer constricted. Returning in 15 minutes is inappropriate.
- A client was admitted to the Mental Health Unit with a diagnosis of depression. After three days, the client is smiling and happy, telling the nurse, "I feel great! I'm ready to go home now." Based on the client's sudden change in behavior, what should the treatment plan include?
- Allowing off-unit privileges
- Increasing suicide precautions
- Asking the client to lead group sessions
- Reducing the doses of medications
Correct answer: Increasing suicide precautions
For a client with depression, a sudden change in behavior can indicate the client has made a decision to inflict self-harm. Increased suicide precautions are necessary to keep the client safe. Other warning signs include sleeping too little or too much, talking about being a burden to others, showing rage or talking about seeking revenge, giving away possessions, or acting extremely calm and peaceful. Extra precautions should be taken during shift changes, when fewer staff members are available.
- A nulliparous woman has a precipitous delivery. The nurse observes that she hesitates to touch her baby and seems unattached to the birth. What is the nurse's most appropriate action?
- Remind the new mother that she should hold her newborn
- Offer support for her feelings about the rapid birth
- Call the social worker to warn about possible abuse
- Put the neonate to her breast to encourage bonding
Correct answer: Offer support for her feelings about the rapid birth
Precipitous delivery is defined as giving birth after 3 hours or less of labor. The mother can be stunned by the rapid process and be in disbelief that her baby has been born so soon. The nurse should offer support and reassurance and let the mother talk about her feelings. The other answer options are not therapeutic.
- A hospice nurse is caring for a male client with cancer. He has acute bone pain related to metastases. The best way to assess the client's level of pain is to
- Ask the client to rate his pain on a scale from 1 to 10
- Note observations of the client's behavior
- Check the client's vital signs after giving him pain medication
- Evaluate the client's verbal and non-verbal actions
Correct answer: Ask the client to rate his pain on a scale from 1 to 10
Only the client can report on his level of pain; it is a subjective perception that should not be judged or dismissed. For managing his care and pain relief, asking him to rate his pain on a scale from 1 to 10 should be the guide.
- After receiving the shift report, the nurse enters the room of a 92-year-old male diagnosed with a cognitive impairment disorder. The nurse asks him what day it is and where he is now. The purpose of this action is to assess for
- Hallucinations
- Orientation
- Sensory impairment
- Awareness disorder
Correct answer: Orientation
The most appropriate way to perform an initial assessment of a client with a cognitive impairment disorder is to assess orientation of time, place, and person.
- Some clients may exhibit false beliefs not supported by facts or reality. This is known as
- Digression
- Delusion
- Dalliance
- Deliberation
Correct answer: Delusion
Delusions are false beliefs that involve a misinterpretation of experiences. Persons suffering from delusions may believe that they are being followed, tricked, or spied on. They may also be convinced that songs or books contain special information meant for them. Attempts to show the person that their belief is wrong or irrational will not be accepted by the person.
- A client with Stage 3 hypertension has been placed on a low-sodium and low-fat diet. He tells the nurse, "I hate this diet, and I won't stay on it. It's too hard." What is the nurse's BEST response?
- Why is this so hard for you? Just swap out the food choices
- Surely your life is more important than what you eat
- No one likes this diet plan. You'll adjust over time
- I can see this is really difficult for you. Let's talk about it
Correct answer: I can see this is really difficult for you. Let's talk about it
Stage 3 hypertension is 160/100 to 179/109. The treatment includes dietary restrictions as well as medication and exercise. Compliance with the treatment plan is important to reduce the risk of developing Stage 4 hypertension (180/110 or higher) or a hypertensive crisis. Learning what the client needs and understanding the situation or emotions can lead to a positive outcome.
- A client with Stage IV bone cancer tells the hospice nurse that he is worried about becoming addicted to the amount of opioids needed to control his pain. What is the best way to address the client's concern?
- Ask the client to lengthen the time between doses
- Remind him that he's receiving care for a terminal disease
- Suggest taking a lower dose, even if he gets more pain
- Explain that opioids taken for pain relief do not result in addiction
Correct answer: Explain that opioids taken for pain relief do not result in addiction
Clients who receive opioid therapy can become concerned about addiction. Research shows that addiction is rare when the medication is taken solely for pain relief. Lengthening the time between doses or lowering the dose is unacceptable for hospice care, when pain control is essential. Reminding the client that he is dying is cruel and unethical.
- A child who has been diagnosed with attention deficit disorder (ADHD) will likely display which of the following behaviors?
- Ability to focus on subjects of interest
- Complaints of somatic illnesses
- Constant movement and squirming
- Attempting to run away
Correct answer: Constant movement and squirming
Constant movement and squirming are indications of ADHD. Other signs include inability to pay attention to directions or details; talking all the time, even when inappropriate; and being easily distracted. Somatic complaints and running away indicate emotional distress.
- Emergency medical personnel bring an unconscious patient to the emergency department. The patient's pupils are pinpoint, and respirations are depressed. Intoxication with which of the following drugs could contribute to these clinical signs?
- Cocaine
- Methadone
- Methamphetamine
- Ecstasy
Correct answer: Methadone
Actions of opioids include constriction of pupils (secondary to parasympathetic stimulation) and depression of respirations (secondary to decreased respiratory center responsiveness to carbon dioxide). The other three drugs are stimulants, which cause pupil dilation, excitability, and increased heart rate and blood pressure.
- A client with Stage IV pancreatic cancer is being discharged from the hospital to her home. She tells the nurse that she doesn't want hospice care because her family will take care of her. What is the nurse's best response?
- I'm wondering how much you know about hospice
- I think your doctor has already ordered hospice for you
- Your care is going to be too much for your family
- This is a huge mistake. I hope you'll reconsider
Correct answer: I'm wondering how much you know about hospice
Many clients believe that hospice is only for support at the time of death. The nurse can provide information about other hospice services: equipment, supplies, and pain control, as well as home health care and support for the client and the family. The client should also know that she can enter hospice care at any time in the future.
- A resident with dementia has wandered into another unit. What should the nurse say after finding the resident?
- Let's go. Don't you know I have work to do?
- Do you think you're Christopher Columbus?
- How on earth did you get here?
- Let's walk back together, OK?
Correct answer: Let's walk back together, OK?
6 out of 10 patients with dementia will wander. Even in the early stages of dementia, residents can become confused for a short time. They may be restless or try to do former activities, such as going to work or "going home."
- The parents of a 16-year-old girl with celiac disease bring their daughter to the clinic because she is having constant, watery diarrhea. The girl tells the nurse that she ate pizza and a hamburger on a bun at a party the night before. She says, "I want to be like my friends. They can eat anything!" When responding to the teenager, which problem should the nurse prioritize?
- Low self-esteem
- Intestinal damage
- Electrolyte imbalance
- Suicidal ideation
Correct answer: Low self-esteem
The teenager tells the nurse that she ate food with gluten because she wants to be like her friends. The nurse can listen and discuss possible ways to have fun without eating gluten and becoming ill. Although there is evidence that she has constant, watery diarrhea, there is no indication of an electrolyte imbalance, intestinal damage, or feelings of self-harm.
- A client in her second trimester of pregnancy is diagnosed with preeclampsia. Which of the following statements is true about her care for the remainder of her pregnancy?
- The client will have to take diuretics to relieve edema in the ankles
- The client has no reason for concern for herself or her baby
- Untreated preeclampsia can result in poor fetal development
- Preeclampsia is the most common cause of delivery after 40 weeks' gestation
Correct answer: Untreated preeclampsia can result in poor fetal development
Preeclampsia is a multisystem, vasospastic disease. Impaired perfusion results in decreased delivery of oxygen and nutrients to the fetus, restricting fetal growth. If preeclampsia is not treated quickly, it can lead to serious complications for the mother, including kidney or liver failure and future cardiovascular problems. It can also cause seizures, resulting in maternal and fetal death.
- To take an adult client's blood pressure, how far should the lower edge of the sphygmomanometer cuff be from the client's antecubital crease?
Correct answer: 2.5 cm
The edge of the blood pressure monitor (sphygmomanometer) cuff should be 2.5 cm (1 inch) from the antecubital crease. The client's arm should be slightly flexed, with the elbow crease at the level of the heart.
- When reviewing a new client's health history with her, the nurse knows that the primary risk factor for cervical cancer is which of the following?
- Maternal history of cervical cancer
- Chlamydia infection, treated 10 years ago
- 20-pack-year history of smoking cigarettes
- Human papillomavirus infection
Correct answer: Human papillomavirus infection
Human papillomavirus (HPV) infection is the primary risk factor for cervical cancer. Over 99% of cervical cancers are caused by strains of HPV. Chlamydia is a bacterial infection, not a virus. Smoking and family history may add to the risk of cervical cancer, but neither of them is the primary risk.
- During a routine check-up, a 22-year-old client tells the nurse that he is losing weight despite being constantly hungry and thirsty. He also admits to urinating more frequently. Which lab tests will likely be ordered?
- ALT, AST, and GGT
- Blood glucose and A1c
- Complete blood count
- 24-hour urine collection
Correct answer: Blood glucose and A1c
Signs and symptoms that indicate type 1 diabetes are increased hunger, thirst, and urination, often accompanied by weight loss and fatigue. Blood glucose shows the current level of blood sugar, and A1c shows the level for the past three months. Liver function tests include ALT, AST, and GGT. A 24-hour urine collection assesses kidney function. A CBC provides a general overview.
- A new client's lab results show a hemoglobin A1c level of 9%. What educational focus will the client need most?
- Self-administering nebulizer medications PRN
- Warning signs and symptoms of hypokalemia
- Learning to take and record daily blood pressures
- Preventing and recognizing hyperglycemia
Correct answer: Preventing and recognizing hyperglycemia
A1c (HbA1c) is a blood test for type 1 diabetes, type 2 diabetes, and prediabetes. It measures the average blood glucose over the past 3 months. A normal Alc is 5.7% or lower. Prediabetes is 5.7-6.4%. Type 2 diabetes is above 6.5%. The client will need to learn how to manage all aspects of living with type 2 diabetes (T2D).
- A 28-year-old woman with a family history of heart disease asks the clinic nurse about the safety of birth control pills. Which lifestyle topic should the nurse assess FIRST?
- Diet preferences
- Smoking history
- Work hazards
- Exercise schedule
Correct answer: Smoking history
Birth control pills do not cause heart disease. Smoking - with or without a history of heart disease - increases the risk of a stroke, blood clot, or heart attack. A woman with a personal history of smoking and a family history of heart disease may need to choose a different method of contraception.
- A 54-year-old male client with chronic kidney disease (CKD) tells the nurse that he loves to have dessert after dinner. Knowing that CKD requires fluid restriction, which dessert should the nurse recommend?
- Ice cream
- Angel food cake
- Any flavor of jello
- Fruit yogurt
Correct answer: Angel food cake
Clients with CKD should limit fluids in foods and avoid foods that become liquid at room temperature, such as jello, sherbet, and ice cream. Semi-solid foods, such as yogurt, should also be considered liquid. Because of thirst, it's better to have more liquid available to drink. Of these options, only angel food cake has the least amount of fluid.
- The Emergency Department physician is admitting a 74-year-old male with a diagnosis of hemorrhagic stroke affecting the right cranial hemisphere. Which assessment is consistent with this diagnosis?
- Homan's sign
- Kernig's sign
- Right-sided spasticity
- Left-sided flaccidity
Correct answer: Left-sided flaccidity
A stroke on the right side of the brain affects the left side of the body, causing flaccidity or paralysis on that side. Homan's sign is a pain in the calf that indicates a deep vein thrombosis. Kernig's sign is an indication of meningeal irritation. Right-sided spasticity is incorrect.
- During his annual physical examination, a client tells the nurse that he would really like to stop smoking. What should the nurse recommend as the client's FIRST step?
- Ask family members and co-workers to provide support
- Immediately dispose of cigarettes and smoking supplies
- Sign and date a formal" Quit" contract with the nurse
- Make a plan to quit smoking within two weeks
Correct answer: Make a plan to quit smoking within two weeks
Setting a date, preferably within two weeks, allows time for the client to make a detailed plan: 1. Inform family, friends, and coworkers. 2. Learn about tobacco withdrawal and how to manage it. 3. Make a list of personal smoking habits, to learn how to avoid them and what to replace them with. 4. When the date arrives, discard all tobacco products and supplies, such as lighters and ashtrays.
- The nurse is teaching a client who has just been diagnosed with genital herpes. Which statement is true?
- This infection will decrease your risk of getting HIV infection
- You will not be contagious if you keep taking your antiviral drugs
- There is no cure for genital herpes, but outbreaks are shorter with the right drugs
- Genital herpes infection is caused by a corkscrew bacterium called a spirochete
Correct answer: There is no cure for genital herpes, but outbreaks are shorter with the right drugs
There is no cure for herpes. Antiviral medications can, however, prevent or shorten outbreaks during the period of time the person takes the medication. Daily use of antiviral medications can reduce the likelihood of transmission to partners. Condoms should always be used to reduce the risk of transmission. When genital herpes is in the ulcerative phase, the risk of acquiring HIV is 2 to 4 times as great if the HIV virus is present.
- A 10-year-old girl lives with her parents, her paternal grandparents, a younger brother, an aunt, and two cousins. What type of family unit is this?
- Extended family
- Nuclear family
- Next-of-kin unit
- Family of origin
Correct answer: Extended family
An extended family is a family that extends beyond the nuclear family, including grandparents, aunts, uncles, and other relatives, who all live nearby or in one household.
- A 58-year-old female asks the nurse if she should still do breast self-examinations. Which statement is most appropriate for the nurse to tell the client?
- You are postmenopausal, so there's no need to continue.
- Do it while you shower on the first day of every month
- Mammograms have entirely replaced the need to do it
- Wait until the week before your yearly mammogram
Correct answer: Do it while you shower on the first day of every month
While breast self-examinations are no longer the primary way to detect cancer, they are still an important part of breast screening strategy. Postmenopausal women can perform a self-exam at the same time every month. During a shower, the woman's fingers can move easily over the breasts to palpate for abnormalities. The other answer options are incorrect.
- The nurse serves on the hospital's Ethics Committee. Which item is appropriate for the committee's agenda?
- A 92-year-old patient who states he was physically abused
- A patient with stage IV cancer who refuses further treatment
- A 16-year-old who elects to place her baby for adoption
- A nurse who was seen taking a patient's controlled drug
Correct answer: A nurse who was seen taking a patient's controlled drug
Ethics is defined as the moral principles that govern a person's behavior or the conducting of an activity. Taking a medication that was prescribed for another person is unethical and should be reported by the nurse who witnesses it. Placing a baby for adoption and refusing treatment are not ethical dilemmas. Elder abuse is a matter for law-enforcement agencies.
- When a nurse reports to work in her medical-surgical unit at the hospital, she is told to go to the obstetrics unit for her shift. The nurse has no experience in obstetrics. What is her most appropriate action?
- Notify the hospital attorney and file a complaint
- Float to the obstetrics unit and perform safe and familiar tasks
- Call the nursing supervisor and ask to go home
- Refuse the assignment and stay in the medical-surgical unit
Correct answer: Float to the obstetrics unit and perform safe and familiar tasks
While no nurse likes to float to another unit, most hospitals do require it to assist with short staffing or similar issues. Refusing an assignment can result in discipline or dismissal. The nurse should report to the new unit and ask for an assignment or tasks that she can perform safely to help the unit.
- An experienced nurse decides to work at a different hospital because it uses the team nursing model, which means that
- Patients receive nursing treatment ordered by a managed care team
- A nurse leads a coordinated team of other nurses and staff
- One nurse provides total care for a team of patients
- Patients are assigned to a team according to nursing tasks
Correct answer: A nurse leads a coordinated team of other nurses and staff
In the team nursing model, a group of healthcare professionals provides complete care for a group of patients. A charge nurse leads the group, which includes CNAs, other nurses, and other staff members.
- After receiving his shift assignment, the nurse realizes that one of his patients is a friend from church. What should the nurse do?
- Ask the patient's spouse to give the bed bath and help with toileting
- Ask another nurse to swap patients for the shift
- Ask the patient if they are uncomfortable receiving care from a friend
- Ask the charge nurse for a different patient assignment
Correct answer: Ask the charge nurse for a different patient assignment
Once the nurse realizes that he has a social relationship with the assigned patient, he should formally request a different patient immediately. Both the nurse and the patient may be uncomfortable with the situation. The patient may not want their private personal information shared, or the patient may not want to receive care from someone whom they know personally. The nurse may not want to know the patient's history or administer what might be interpreted as "inappropriate" care.
- When a nurse writes an end-of-shift report, which piece of information is most important to share with the oncoming nurse?
- Results of all labs and tests since admission
- Total number of all medications given during the shift
- Evidence of excellent care by the outgoing nurse
- PRN medications given and the outcome
Correct answer: PRN medications given and the outcome
Shift reports should be a summary of each client's condition during that shift, including any PRN medications and the outcome; changes in the client's condition, and specific concerns. Scheduled tests for the next shift can be relayed.
- The physician talks with a client and gives full details about an upcoming procedure. The client agrees to it, so the nurse asks the client to sign the consent form. The client tells the nurse that he never learned to write. What is the BEST action for the nurse?
- Ask a family member to sign the consent as a proxy
- Get two nurses to witness the client sign the consent with an X
- Contact the physician at once to cancel the procedure
- Review the document with the client and obtain verbal consent
Correct answer: Get two nurses to witness the client sign the consent with an X
The physician or other provider performing the procedure obtains informed consent from the client and answers all questions. The physician or provider can also obtain verbal consent. The nurse's responsibility is to ensure that the signed consent is on the client's chart before the procedure and verify the physician's role. Clients who cannot write may sign with an X, with two witnesses to the signature.
- Which process in Quality Improvement helps identify the fundamental problem of an event or trend?
- People caused effect
- Probable cause analysis
- Cause and effect
- Root cause analysis
Correct answer: Root cause analysis
Root cause analysis is a Quality Improvement technique that is used to identify the underlying, root causes of a problem. Root cause analysis focuses on process flaws and NOT on people who have erred or made a mistake. The other answers are not Quality Improvement terms.
- A nurse watches a new nursing assistant care for a post-stroke patient with left-sided paralysis. Which action by the nursing assistant requires the nurse to intervene?
- The nursing assistant applies a gait belt around the patient's waist prior to ambulating.
- The nursing assistant places the patient in the supine position with the head turned to the side
- The nursing assistant praises the patient for attempting to perform all ADLS with minimal help
- The nursing assistant tries to move the patient up in bed by placing a hand under the patient's left axilla
Correct answer: The nursing assistant tries to move the patient up in bed by placing a hand under the patient's left axilla
The nurse should intervene because it is not appropriate to pull a patient up in bed by the patient's armpits. Attempting to pull on a flaccid shoulder joint could cause shoulder dislocation. Always use a lift sheet for both patient and staff safety. All the other actions are appropriate.
- The brother of a client stops by the nurses' station to ask about the client's recovery from bowel surgery related to Crohn's disease. The brother asks, "How's he doing? Will he get better?" What is the nurse's most appropriate response?
- He's doing great. The surgery was successful, and he'll be home soon
- His medical information is private, so I can't share any details with you
- Since you're a family member, I can let you know he's doing well
- He has a slight fever, so we'll be starting him on antibiotics today
Correct answer: His medical information is private, so I can't share any details with you
The Health Insurance Portability and Accountability Act (HIPAA) states that no healthcare provider can share information about a client without the client's consent. There is only one correct choice for this question. The other three answer options each reveal something about the client's condition.
- EMS transports a trauma patient to the Emergency Department. On arrival, the patient is unconscious and bleeding profusely from several wounds. Immediate surgery is necessary. What should the nurse do about obtaining informed consent?
- Send the patient to surgery without informed consent
- Ask the charge nurse to contact an administrator for a court order
- Approach the friend who followed the EMS to give informed consent
- Attempt to reach the patient's next of kin to obtain consent
Correct answer: Send the patient to surgery without informed consent
When a life-threatening emergency requires immediate action, every moment counts. Attempting to obtain informed consent would delay intervention. In this situation, sending the patient to surgery is the legal and ethical action.
- A nurse is witnessing a client's signature on a consent document before the client's surgical procedure. Which statement by the client should make the nurse stop the process?
- I believe the surgery is better than the other alternatives
- I can still change my mind if I decide to wait for the operation
- I'm not sure what this surgery is for, but I'll sign it anyway
- I know this surgery is risky, but I'm willing to go ahead with it
Correct answer: I'm not sure what this surgery is for, but I'll sign it anyway
Informed consent is the client's agreement to have their body touched by a specific individual. The client's questions about the surgery or procedure must be answered by the person performing the surgery or procedure before the client signs the consent. The other answer options do indicate that the client is giving an informed consent.
- A 22-year old mother from Mexico arrives at the Emergency Department with her 3-month old daughter, who has a temperature of 100.6 °F (38.1 °C) and signs of sepsis. The ED physician orders a lumbar puncture, but the mother is hesitant to consent until her husband arrives. What should the ED nurse do?
- Tell the ED physician that the mother refuses
- Ask the ED social worker to intervene
- Keep trying to contact the husband
- Contact the Department of Children's Services to report child abuse
Correct answer: Keep trying to contact the husband
In Mexican and other Hispanic cultures, the male is head of the household and makes major decisions. The nurse should keep trying to reach the baby's father. Symptoms of sepsis in newborns and young babies include poor feeding, vomiting, fever (above 100.4 °F (38 °C) rectally) or sometimes low temperatures, pale skin, cool extremities, and irritability.
- The nurse is making client assignments for the shift. Which of the following clients is most appropriate for a Certified Nursing Assistant (CNA)?
- Client who requires wound irrigation
- Client with dementia who needs frequent redirection
- Client in isolation with airborne precautions
- Client with chest pain who is a new admit
Correct answer: Client with dementia who needs frequent redirection
A CNA has the skills to assist and redirect a client with dementia. This helps free the nurse to monitor other clients with more complex conditions and perform tasks that are beyond the scope of practice for the CNA.
- Before their first overnight excursion, a camp nurse instructs a group of campers on how to prevent Lyme disease. Which statement by a camper indicates to the nurse that more teaching is needed?
- I'll wear long pants and long-sleeved shirts, even if it's hot
- If I dress properly, I won't need to use that smelly insect repellent
- I need to get a hat before we go. I didn't bring one
- It'll look weird, but I'll pull my socks up over my pant legs
Correct answer: If I dress properly, I won't need to use that smelly insect repellent
Lyme disease is caused by bacteria transmitted through the bite of the tiny deer (black-legged) tick found in the eastern and central United States or the western black-legged tick found in the western United States. To avoid getting bitten by a tick, follow these rules: 1. Avoid tick-infested areas, particularly in May, June, and July. 2. When you're outside in areas where there may be ticks, wear shoes, long pants tucked into socks or pant legs, and long sleeves. 3. Use insect repellent with 20-30% DEET around your ankles, other areas of bare skin, and clothes. 4. After being in areas where there may be ticks, check for ticks on your person, especially around the armpits, groin, waist, scalp, neck, and head. 5. Remove deer ticks on your skin as soon as you see them.
- An infection acquired in a hospital setting is called
- Prionitic
- Iatrogenic
- Nosocomial
- Noncommunicable
Correct answer: Nosocomial
Nosocomial means an infection acquired from being in the hospital. Sick patients bring numerous pathogens into hospitals, and some of these pathogens are easily transmitted by dirty linens, call buttons, or door handles, or by clinicians, nurses, or therapists who do not wash their hands before touching a patient.
- After the RN receives an order for a belt restraint for a resident, a Certified Nursing Assistant (CNA) applies the restraint. When the nurse checks the restraint 15 minutes later, which observation would indicate that the restraint is unsafe?
- The resident is able to turn from back to side
- The restraint does not tighten with force
- Restraint straps are attached to the side rails
- The restraint is tied with a quick-release knot
Correct answer: Restraint straps are attached to the side rails
Tying the restraint to the side rails is both unsafe and incorrect. The resident could be injured if the side rails are lowered. The restraint straps should be attached to the bed frame. The other answer options are safe and correct.
- A patient hospitalized with MRSA (methicillin-resistant Staphylococcus aureus) is placed on contact precautions. Which statement is true?
- The risk of transmission is high, so the patient should wear a mask
- The patient must be placed in a room with negative pressure
- MRSA requires frequent contact, so the door should remain open
- Transmission can be prevented by hand hygiene, gloves, and a gown
Correct answer: Transmission can be prevented by hand hygiene, gloves, and a gown
The CDC recommends a private room for patients requiring contact isolation. When caring for a client with MRSA, gloves, a gown, and a mask should be worn. Proper handwashing before and after patient care is essential. The door should remain closed, but a negative-pressure room is not indicated. MRSA is spread by contact with the patient's blood or body fluids or by touching the patient's skin. It can be cultured from the nasal passages, so instruct the patient to cover his nose and mouth when he sneezes or coughs. A mask for the patient is not necessary.
- During her shift in the medical-surgical unit, a nurse learns that heavy fog has caused a serious multi-car pileup on the nearby highway, resulting in serious trauma injuries. According to standard disaster protocol, what is the nurse's best action?
- Line up gurneys in the hall and prepare them for admissions
- Hand over your patient load to another nurse and go to the ED to help
- Make a list of noncritical patients who can be discharged from the unit
- Call in other nurses and staff to help handle the incoming patients
Correct answer: Make a list of noncritical patients who can be discharged from the unit
When multiple trauma admissions are expected from a disaster or emergency, standard procedure requires low-risk and noncritical patients to be discharged to make room for more acute admits. The patients may be transferred to another facility, to a convalescent or rehabilitation center, or to home with home health nursing. The nurse should adhere to the hospital's disaster plan.
- While passing meal trays, the nurse notices that a client with a severe latex allergy has been served a food that the client should not eat. Which food is it?
- Cereal
- Banana
- Pudding
- Salmon
Correct answer: Banana
Latex is made from rubber trees, which are in the same plant family as a banana tree. 30-50% of individuals who are allergic to natural rubber latex (NRL) show an associated hypersensitivity to some plant-derived foods, especially freshly consumed fruits. This association of latex allergy and allergy to plant-derived foods is called latex-fruit syndrome. An increasing number of plant sources, such as avocado, banana, chestnut, kiwi, peach, tomato, potato and bell pepper, have been associated with this syndrome. The other foods will not cause a cross-reaction.
- While ambulating, a resident has slipped onto the floor and is unable to get up by himself. What is the best way to get him back on his feet?
- Call security to help
- Use a mechanical lift
- Try a blanket lift
- Attach a gait belt
Correct answer: Use a mechanical lift
The best way to assist the resident without injuring him, the nurse, or anyone else is to use a mechanical lift. First assess the resident, then assist him to a comfortable position. The other options are incorrect.
- According to the CDC, when removing personal protective equipment (PPE), which item should you remove first?
Correct answer: Gloves
The Centers for Disease Control and Prevention recommends removing PPE in an order that minimizes contamination from pathogens. Because gloves are the "dirtiest," they should be removed first. To make it easy to remember, remove the PPE in alphabetical order: gloves, goggles, gown, mask.
- A member of the healthcare team experiences a needlestick from a contaminated needle. Which of the following can provide passive immunity against the hepatitis B virus?
- Hepatitis B immune globulin
- Interferon injection
- Antiviral medication
- Hepatitis B vaccination
Correct answer: Hepatitis B immune globulin
Hepatitis B immune globulin (HBlg) contains IgG antibodies specific to hepatitis B, which provide passive immunity. Passive immunity means that a person is given antibodies to a disease instead of producing them through their own immune system. HBlg is used for prophylaxis after exposure to the hepatitis B virus.
- If a nurse is assigned to care for a patient with a Sengstaken-Blakemore tube, which item MUST be kept at the patient's bedside?
- Scissors
- A hemostat
- Sutures
- A Yankauer
Correct answer: Scissors
A Sengstaken-Blakemore tube is a medical balloon device inserted through the nose or mouth and used in the management of upper gastrointestinal hemorrhage caused by esophageal varices. If the tube ruptures, scissors are used to cut the balloon and prevent blocking the patient's airway. A hemostat is used to clamp blood vessels or tubing, because it can lock. A Yankauer is used for oral suctioning. Sutures are for wound closure.
- When caring for a patient diagnosed with viral hepatitis, the nurse experiences a needlestick from a contaminated needle. Which of the following actions should the nurse perform first?
- Report to the emergency department
- Put the needle in a biohazard bag for testing
- Make an appointment with the infection control department
- Wash the area thoroughly with soap and water
Correct answer: Wash the area thoroughly with soap and water
The puncture site and skin should be washed thoroughly with soap and water. Then the nurse should follow the next steps in the facility-specific protocol for when a needlestick occurs. Typically, after reporting the incident to your supervisor, you will be directed to seek immediate treatment.
- During a unit staff meeting, the nursing supervisor reports on a recent infection control audit. Which finding indicates a need for staff training?
- A lab technician puts on a mask, gown, and gloves before entering the room of a patient on strict isolation
- A certified nursing assistant does not wear gloves when feeding an elderly patient
- A patient with active tuberculosis wears a mask when going to another department for testing
- A nurse with open lesions on her hands puts on gloves before giving direct patient care
Correct answer: A nurse with open lesions on her hands puts on gloves before giving direct patient care
There is no need to wear gloves when feeding a client. However, universal (standard) precautions (treating all blood and body fluids as if they were infectious) should be followed in all situations. A client with active tuberculosis should be on respiratory precautions, including wearing a mask outside their private room. Staff members with exudative lesions or weeping dermatitis should not give direct care or handle patient care equipment until the condition resolves, not even while wearing gloves. Strict isolation requires the use of mask, gown, and gloves for anyone entering the room.
- A nurse prepares to care for a newly admitted patient who recently had a cerebrovascular accident (CVA). For this patient, what is the best way to prevent an infection?
- Implement Universal Precautions at once
- Use a bedside commode instead of a bedpan
- Place a mask on the patient when they are ambulating
- Wear a gown and gloves when providing care
Correct answer: Use a bedside commode instead of a bedpan
Sitting upright on a commode is preferable to using a bedpan because the patient is able to sit upright, which makes it easier to empty the bladder. The other answer options are incorrect. The term "universal precautions" refers to the concept that all blood and bloody body fluids should be treated as infectious because patients with bloodborne infections can be asymptomatic or unaware they are infected. A mask is necessary only if the patient is at risk of infection. Wearing a gown and gloves is incorrect.
- A client who just had a right total knee replacement tells the nurse that he can't lift his right ankle, and the top of his right foot feels numb. The nurse suspects which of these postoperative complications?
- Blood clot
- Joint dislocation
- Nerve damage
- Hemorrhage
Correct answer: Nerve damage
Foot drop is caused by damage to the peroneal nerve, which innervates the muscles in the legs that lift the ankle and toes upward (dorsiflexion). The nerve also provides sensation to the top of the foot. The other answer options are incorrect.
- The nurse is instructing a client with a new ileostomy on when to empty their pouch. Which of the following instructions is correct?
- Empty it when it is 1/3 to 1/2 full.
- Empty the pouch before every meal.
- Empty the pouch when it feels heavy.
- Empty it at the same time every day.
Correct answer: Empty it when it is 1/3 to 1/2 full.
The pouch should never become more than half full; one-third full is best. A full pouch is heavy and can loosen the seal, causing a leakage. lleostomy output will be liquid or pasty depending on the client's diet. They will need to empty their pouch 6-8 times per day.
- Which of the following assessment findings is consistent with an extracellular fluid volume deficit?
- Hypertension
- Bradycardia
- Oliguria
- Hyperglycemia
Correct answer: Oliguria
Oliguria is a sign of an extracellular fluid volume deficit. Extracellular fluid is the body fluid not contained within individual cells. It constitutes about 20% of our body weight and includes blood plasma, lymph, spinal cord fluid, and the fluid between cells. Importantly, this fluid isn't just water, it contains electrolytes and other essential solutes. Common causes of oliguria are blood loss, vomiting and diarrhea, polyuria, excessive sweating, and burns. The other answer options are not related to fluid deficit or hypovolemia.
- During an initial client assessment, which of the following techniques will the nurse use to gather subjective data?
- Describe the client's behavior.
- Auscultate heart and lungs.
- Review laboratory results.
- Conduct a client interview.
Correct answer: Conduct a client interview.
Information obtained from the client's perspective is subjective. Laboratory results and physical assessments are objective data. Describing the client's behavior without any interpretation or bias is also considered objective.
- An unconscious trauma patient is admitted to the ICU. The health care provider (HCP) prescribes enteral feedings via the nasogastric (NG) tube. Before the nurse administers a formula feeding, which finding by the nurse requires IMMEDIATE action?
- Bowel sounds are hypoactive in all quadrants.
- Urine output for the last 8 hours was 40 mL/hr.
- The volume of residual formula is 90 mL.
- Breath sounds are decreased in the right lower lobe.
Correct answer: Breath sounds are decreased in the right lower lobe.
A major risk associated with enteral feedings is aspiration, resulting in atelectasis and pneumonia. The right lower lobe (RLL) is the most common site. Clients should be positioned at a minimum of 30 degrees of head elevation during feedings and up to two hours afterward. The nurse should verify tube placement before each feeding, or every four to eight hours if the client is receiving a continuous feeding. Residual volumes of up to 100 mL are acceptable. Urine output of less than 30 mL/hr should be reported to the HCP. Decreased bowel sounds should be monitored but are not an immediate concern.
- One of the nurse's patients has a nasogastric (NG) tube for tube feedings and medications. Which nursing action is appropriate when caring for this patient?
- Check the area where the tape is applied qd.
- Flush the NG tube q 4 hr with hot water.
- Change the tubing from the feeding a 48 hr.
- Place the bed in the tow Fowler's position for feedings.
Correct answer: Check the area where the tape is applied qd.
The nurse should change the tape at the patient's nose every day and assess the skin for breakdown. Tubing and feeding items are replaced every 24 hours. The NG tube is flushed with warm water to avoid burning the patient or causing discomfort. The bed is placed in the high Fowler's position for tube feedings.
- A pregnant client comes to the prenatal clinic for her first visit. The nurse notes that this is the client's third pregnancy. Four years ago, she delivered a healthy boy at 38 weeks, and two years ago, she delivered a healthy girl at 35 weeks. Using the gravida/para system to record the client's obstetrical history, the nurse will document
- Gravida 3 – Para 2.
- Gravida 2 - Para 1.
- Gravida 3 - Para 1.
- Gravida 2 - Para 2.
Correct answer: Gravida 3 – Para 2.
Using the gravida/para system, the nurse should record Gravida 3- Para 2. The client is pregnant for the third time (Gravida 3) and has had two pregnancies of more than 20 weeks' gestation each (Para 2). The other options are incorrect.
- A child with a new diagnosis of celiac disease is being discharged. The nurse provides education to the parents, including appropriate nutrition for their child. The nurse will instruct the parents to follow a
- Fat-restricted diet
- Phosphorus-restricted diet
- Gluten-free diet
- Lactose-free diet
Correct answer: Gluten-free diet
Celiac disease results in an inability to tolerate wheat, barley, rye, and oats. A gluten-free diet is prescribed for a child with celiac disease. A lactose-free or lactose-restricted diet is prescribed for a child with lactose intolerance or diarrhea. A fat-restricted diet is prescribed for a child with disorders of the liver, gallbladder, or pancreas. Phosphorus restrictions are part of a renal diet, which also limits sodium and protein.
- A client with diabetes insipidus has urine output described as
- Oliguria
- Polyuria
- Anuria
- Dysuria
Correct answer: Polyuria
Polyuria is a primary symptom of diabetes insipidus, with urine output more than 3 L/day. These clients have decreased or absent vasopressin secretion, which causes water loss in the urine and increased serum sodium. Anuria is the absence of urine output. Oliguria is urine output of less than 500 mL/day. Dysuria is difficult or painful urination.
- Which skin care instruction is correct for a male client receiving head and neck radiation therapy?
- Use an antibacterial soap every day.
- Apply lotion right before each treatment.
- Avoid shaving with a straight-edge razor.
- Cover the treated area with sterile gauze.
Correct answer: Avoid shaving with a straight-edge razor.
During radiation therapy, the client should use an electric razor to avoid irritation or cuts. Antibacterial soaps are too harsh; a mild soap should be used instead. The radiation area is left open to the air. Lotion may be used several times a day, but not 4-5 hours before a treatment. Lotions or creams should not be applied over the radiation marks.
- A nursing home resident tells the nurse on the day shift, "No one answered my call light last night! I called and called, but one of them told me they had other residents to care for. I'm so sick, but no one cares." What is the nurse's best response?
- Oh, you poor thing! I'll file a negligence report before I leave today.
- It's hard to have to ask for help and feel that no one helps.
- You're right. I will let the nursing supervisor know right away.
- You're being too impatient. Our nursing staff comes as soon as they can.
Correct answer: It's hard to have to ask for help and feel that no one helps.
The nurse should reflect the resident's perceptions and feelings through empathy. Statements that are judgmental or patronizing are not therapeutic. Every shift is different, and the staff may have been occupied with situations that were more critical. But the nurse's task is to assist this resident with their perceptions and feelings.
- The tool that predicts the risk of developing a hospital- or facility-acquired pressure ulcer or injury is called the
- Apgar Scale
- Likert scale
- Braden Scale
- Misophonia Scale
Correct answer: Braden Scale
The Braden Scale uses a score from less than or equal to 9 to as high as 23. The lower the number, the higher the risk for developing an acquired ulcer or injury. The Braden Scale should be used on admission, transfer, and receiving, and with any change in the client's condition. The Likert Scale is used on questionnaires. The Misophonia Scale is used for a disorder in which certain sounds trigger emotional or physiological responses. The Apgar Scale measures the health of a newborn.
- A nurse is teaching parents how to administer ear drops to their 18-month-old daughter, who has otitis media. Which instruction is correct?
- Chill the ear drops before administering them
- Pull her earlobe down and back before instilling the drops
- Always wear gloves when giving ear drops to a child
- Pull her outer ear up and back before instilling the drops
Correct answer: Pull her earlobe down and back before instilling the drops
For children who are under 3 years of age, gently pull the earlobe down and back before instilling the drops. For children over 3 years of age, gently pull the ear up and back first. Ear drops are usually stored at room temperature. If not, warm them to room temperature to prevent the child from feeling dizzy or nauseated. Handwashing is sufficient before and after instilling the drops.
- A gunshot victim who is bleeding profusely is transported to the Emergency Department by EMS. The ED specialist orders an immediate blood transfusion. Without a crossmatch, which blood type will be sent by the blood bank?
- AB negative
- AB positive
- O positive
- O negative
Correct answer: O negative
In emergency situations, without time for a type and crossmatch, O negative blood will be transfused. (Think, "Oh, no!" to remember.) Type O, Rh negative is the universal blood donor type and can be received by all other blood types. Type AB, Rh positive is the universal recipient type and can accept blood from any other blood type.
- A client is prescribed a calcium channel blocker to treat primary hypertension. When teaching the client about the medication, which of these foods will the nurse advise the client to avoid?
- Bananas
- Grapefruit
- Milk
- Eggs
Correct answer: Grapefruit
Grapefruit and its juice contain furanocoumarins, which inhibit the cytochrome P450 enzyme CYP3A4. CYP3A4 is involved in metabolizing many drugs, including calcium channel blockers. Medication blood levels can increase, becoming toxic. The levels of calcium channel blockers are increased when grapefruit or grapefruit juice is consumed, potentially causing hypotension. Grapefruit can interfere with other drugs too, including statins (atorvastatin, lovastatin, simvastatin), some antibiotics, and some cancer drugs.
- A client with a diagnosis of emphysema is taking aminophylline PO. What is the reason for this medication?
- It dilates the bronchial airways
- It thins secretions from the lungs
- It suppresses persistent coughing
- It reduces thick sputum production
Correct answer: It dilates the bronchial airways
Aminophylline dilates the bronchial airways, increasing vital capacity. It is used to prevent and treat wheezing, shortness of breath, chronic bronchitis, emphysema, and other lung conditions. The other answer options are incorrect.
- Parents of a 9-year-old girl with a new diagnosis of type 1 diabetes (T1D) ask the nurse what caused their daughter's disease. The nurse knows the pathology is which of the following?
- Increased hepatic glycogenesis
- Atrophy of alpha cells in the pancreas
- Pancreatic beta cell destruction
- Cells becoming resistant to insulin
Correct answer: Pancreatic beta cell destruction
Insulin is produced by the beta cells in the pancreas. When the beta cells are destroyed, no insulin is available. It must be provided by a source outside the body. The other options are incorrect.
- If a client has a known allergy to penicillin, which of the following prescriptions is NOT suitable?
- Sulfonamide, such as Bactrim or Septra
- Aminoglycoside, such as Gentamicin or Tobramycin
- Tetracycline, such as Sumycin or Tetracon
- Cephalosporin, such as Ancef or Rocephin
Correct answer: Cephalosporin, such as Ancef or Rocephin
Penicillin and cephalosporins have a similar chemical structure, so there is a greater chance of cross-reactivity. Any client with a drug allergy should be observed for adverse reactions, especially to antibiotics.
- A client with a seizure disorder is prescribed phenytoin 0.2 gm PO bid. The pharmacy sends 100 mg capsules. How many capsules will the nurse administer for each dose?
- 10 capsules
- 5 capsules
- 1 capsule
- 2 capsules
Correct answer: 2 capsules
Convert grams to milligrams by multiplying by 1,000: 0.2 g×1000=200 mg. Then 100 mg200 mg=2 capsules. The nurse will administer 2 capsules of phenytoin (Dilantin) for each dose.
- A resident has an order for heparin 5,000 units SC q 12 hrs. The heparin vial is labeled 10,000 units/mL. How many mL should the nurse administer?
- 0.5 mL
- 1.20 mL
- 0.20 mL
- 5.0 mL
Correct answer: 0.5 mL
Divide the required dose by the available concentration of 10,000 units/mL: 10,000 units/mL5,000 units=0.5 mL.
- The client's physician orders a medication dose of 150 mg. The pharmacy sends the medication in a liquid, 100 mg/10 mL. How many mL will the nurse administer for the correct dose?
Correct answer: 15 mL
1. Calculate how many mg are in each mL: 10 mL100 mg=10 mg/mL. 2. Divide the prescribed dose by the dose per mL: 10 mg/mL150 mg=15 mL.
- The clinic nurse reviews a new client's over-the-counter (OTC) medications with the client. The client admits to epigastric pain. Which medication is the likely cause?
- Diphenhydramine, taken for allergies
- Dextromethorphan, taken for coughs
- Aspirin, taken for osteoarthritis
- Milk of magnesia, taken for constipation
Correct answer: Aspirin, taken for osteoarthritis
Although aspirin (ASA) has analgesic, anti-inflammatory, antipyretic, and antiplatelet benefits, it is also a gastric irritant. It should be administered with food, milk, or a full glass of water. Enteric-coated or buffered forms will reduce gastric irritation and the risk of bleeding. The other answer options are not associated with gastric irritation.
- Post-op orders for a client include 2 mg hydromorphone hydrochloride (Dilaudid) IM 3 hours for pain. The pharmacy sends a vial labeled 4 mg/1 ml. How much will the nurse administer every 3 hours?
- 0.60 mL
- 0.75 mL
- 0.25 mL
- 0.50 mL
Correct answer: 0.50 mL
Use this formula to calculate dosage: dose availabledesired dose×vehicle. 4 mg2 mg×1 mL=0.5 mL.
- A respiratory therapist administers epinephrine in a 1:100 solution by nebulizer inhaler. The nurse knows that the percentage strength of the epinephrine is
Correct answer: 1.00%
A drug with a 1:100 ratio is a 1% solution. Here is how to calculate it: 1:100 equals 1/100 equals 0.01. 0.01 x 100 = 1%.
- A nurse is teaching a client with hypertension about taking a thiazide diuretic. Which of the following statements by the nurse is correct?
- With this medication, you'll need to eat foods that have potassium
- I'll teach you how to count your pulse before taking this medication
- Take this medication at dinner with a large glass of water
- Stop taking this medication if you start urinating frequently
Correct answer: With this medication, you'll need to eat foods that have potassium
Thiazide diuretics increase sodium (Na) delivery to the distal tubules of the kidney, which also increases the loss of potassium (K). Clients should be instructed to eat plenty of potassium-rich foods, such as bananas, oranges, cantaloupe, cooked spinach, and many types of beans. Diuretics are taken in the morning so that the client can urinate while awake. The other two answer options are incorrect.
- A client with depression should be monitored for constipation and urinary retention. Which of the following factors contribute to these conditions?
- Slow digestion and medication side effects
- Eating only foods that appeal to the client
- Inadequate diet and limited fluid intake
- Poor nutrition and lack of moderate exercise
Correct answer: Slow digestion and medication side effects
The correct answer option addresses both urinary retention and constipation. Medication side effects can cause urinary retention. Constipation can be caused by diet, lack of exercise, and lack of proper hydration. Eating only foods that appeal to the client is incorrect.
- Which is the best position for postoperative coughing and deep breathing?
Correct answer: Fowler's
All surgical patients are at risk for postoperative respiratory complications, such as pneumonia. By sitting up in a Fowler's position, patients can use a pillow to splint their incision while expanding their lungs as much as possible.
- The nurse is teaching a client with emphysema how to do pursed-lip breathing. The nurse knows it will help the client because
- It increases the respiratory rate and oxygenation levels
- It will help the client achieve maximum inhalation
- It helps keep the small airways open and prevents air trapping
- It creates negative pressure in the airways
Correct answer: It helps keep the small airways open and prevents air trapping
Decreased elastic recoil results in airway collapse during expiration. Air gets trapped in the lungs, and exhalation becomes difficult. Pursed lip breathing improves ventilation by keeping the small airways open and releasing air that is trapped in the lungs.
- The nurse is getting ready to help a client ambulate for the first time since his cardiac surgery. Which device will be safest?
- Gait belt
- Walker
- Cane
- Crutches
Correct answer: Gait belt
A gait belt is used for clients who may be weak or have balance issues. If the client starts to fall, the nurse can control the fall by gently lowering the client onto the floor. A cane is the least stable of these four options. Crutches are for transferring weight to the upper body. A walker is for clients who need support when walking without assistance.
- A nurse is checking a client's stool for occult blood. However, the nurse knows that ____can cause a false-positive result.
- Dairy products
- Fried potatoes
- Rare steak
- Red jello
Correct answer: Rare steak
Steak is a red meat. Red meat is high in iron, which can cause a false-positive result. How the meat is is cooked doesn't matter. All red meats (beef, pork, lamb, and liver) should be avoided for three days before testing the stool for occult blood.
- The nurse is caring for a 3-month-old infant with infectious gastroenteritis. The infant is lethargic, and the mucous membranes are dry. Which other finding indicates moderate dehydration?
- Increased thirst
- Loss of gag reflex
- Sunken fontanelle
- No urine output
Correct answer: Sunken fontanelle
A sunken fontanelle is a sign of increasing dehydration. It is first noticed when dehydration progresses from mild to moderate. Mild dehydration may be evidenced by increased thirst and decreased urine output. Anuria (no urine output) is a sign of severe dehydration.
- During a code for an unresponsive infant, which pulse location should the nurse palpate?
- Carotid
- Pedal
- Brachial
- Radial
Correct answer: Brachial
For an infant, the best place to check for a pulse is the brachial artery. To locate the brachial artery, place 2 or 3 fingers on the inside of the upper arm between the shoulder and elbow. Press the fingers gently for 5 to 10 seconds to feel for a pulse. Pushing too firmly may occlude the infant's pulse. Because of fatty tissue around an infant's neck, the carotid artery can be difficult to locate. Pedal and radial pulses are unreliable.
- A child with a peanut allergy has also been diagnosed with asthma recently. A nurse instructs the parents on ways to prevent the child from coming into contact with peanuts. This is necessary because the child is at increased risk for which of the following?
- Anaphylaxis and respiratory failure
- Sudden headache and seizures
- Painful raised rash and urticaria
- Projectile vomiting and diarrhea
Correct answer: Anaphylaxis and respiratory failure
The child who has asthma is at the greatest risk of death secondary to anaphylaxis. Anaphylaxis is a severe Type I hypersensitivity reaction, which can be caused by a food allergy. Type I hypersensitivity reactions can cause a variety of signs and symptoms, depending on the severity of the hypersensitivity response.
- The results of an adult client's blood pressure screening on three occasions are 120/80 mmHg, 130/76 mmHg, and 118/86 mmHg. How will the client's physician interpret this information?
- Hypertension Stage 1
- Normal blood pressure
- Elevated blood pressure
- Hypertension Stage 2
Correct answer: Hypertension Stage 1
A client is considered to have hypertension if even one of the parameters (either diastolic or systolic) is elevated. This patient has stage 1 hypertension, defined as 120–139 mmHg systolic or 80-89 mmHg diastolic. "Elevated blood pressure" replaces the previously used term of prehypertension.
- A patient with second- and third-degree burns on both legs received an initial treatment of topical antimicrobial agents. Then the legs were wrapped with sterile dressings. On performing a routine assessment, the nurse finds pedal pulses are diminished. What is the FIRST action for the nurse?
- Recheck in 15 minutes
- Remove the dressings
- Loosen the dressings
- Elevate the legs
Correct answer: Loosen the dressings
Because edema is a common complication with burns, the patient should already have both legs elevated on pillows, with routine checks, including peripheral pulses, every two hours. Peripheral pulses are the posterior tibial (ankle) and dorsalis pedis (foot). If pulses are diminished, the FIRST step is to loosen the dressings and recheck the pulses to determine whether the dressings were wrapped too tightly.
- Before administering a client's daily dose of furosemide, the nurse checks the client's morning serum potassium level. Which lab value should cause the nurse to hold the dose and report the result to the client's physician?
- 3.7 mEq/L (3.7 mmol/L)
- 4.7 mEq/L (4.7 mmol/L)
- 3.2 mEq/L (3.2 mmol/L)
- 4.2 mEq/L (4.2 mmol/L)
Correct answer: 3.2 mEq/L (3.2 mmol/L)
The normal serum potassium level in an adult is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). Of these four choices, only 3.2 mEq/L is outside the normal range. If the client has a history of heart disease, giving furosemide with a low serum potassium level could trigger ventricular dysrhythmias.
- A postoperative patient has developed thrombophlebitis in a leg. The physician has ordered heparin sodium 7500 units SC q 12 hours. Which lab value should the nurse report to the physician before administering the heparin?
- Complete blood count (CBC)
- Prothrombin time (PT)
- Glycated hemoglobin (HbA1c)
- Partial thromboplastin time (PTT)
Correct answer: Partial thromboplastin time (PTT)
Partial thromboplastin time (PTT) is used to monitor and prescribe varying heparin doses. The therapeutic range is 1.5 to 2.5 times the control time. HINT: The two Ts in PTT resemble an H, and H stands for heparin. Prothrombin time (PT) is used to monitor oral anticoagulant therapy, such as warfarin. CBC reports the total number of blood cells. HbA1c is a value used for diabetic management and control.
- When assessing a sacral pressure ulcer, the nurse observes that the sore has partial thickness, loss of dermis, and a reddish wound bed. No slough is apparent. What stage is this pressure ulcer?
- Stage I
- Stage III
- Stage II
- Stage IV
Correct answer: Stage II
Stage I pressure ulcers have intact skin and a reddened area. Stage Il ulcers have partial-thickness loss of dermis and a pink-red wound bed, with no slough present. Stage Ill pressure ulcers have full-thickness loss of dermis and may contain slough. Stage IV ulcers have full-thickness dermis loss and exposed bone, muscle, or tendons. Eschar and slough may be present.
- Which option CORRECTLY matches the description of a pressure ulcer with its stage?
- Stage II: Damaged or loss of epidermis and partial dermis layers
- Stage IV: Loss of skin layers has exposed some fat tissue
- Stage III: The pressure ulcer has slough and eschar
- Stage 1: Significant blanching when pressure is applied to the skin
Correct answer: Stage II: Damaged or loss of epidermis and partial dermis layers
A Stage Il pressure ulcer damages the epidermis and part of the dermis. A Stage I pressure ulcer remains intact, and the skin doesn't briefly lighten or blanch when touched. A Stage III pressure ulcer is a deep wound that can expose some fat. A Stage IV pressure ulcer exposes bone, muscle, and tendons. It is also characterized by slough and eschar.
- A 72-year-old female is admitted with severe diarrhea. The nurse monitors the patient for which acid-base imbalance?
- Respiratory acidosis
- Metabolic alkalosis
- Respiratory alkalosis
- Metabolic acidosis
Correct answer: Metabolic acidosis
With severe diarrhea, bicarbonate HCOX3X− in the intestines may be lost, resulting in metabolic acidosis. Other causes of metabolic acidosis are nasogastric (NG) suctioning, renal failure, and some medications.
- A nurse's neighbor calls in a panic to tell the nurse that her 2-year-old son has just eaten a detergent pod. What should the nurse tell the mother to do FIRST?
- Call the Poison Control Center
- Call Emergency Medical Services
- Go to the Emergency Department
- Induce vomiting with syrup of ipecac
Correct answer: Call the Poison Control Center
With any possibility of poisoning, always call the Poison Control Center for instructions. 1-800-222-1222 is available 24 hours a day. Vomiting is not always recommended, and it can be harmful. The other two answer options can waste valuable time.
- A nurse is invited to speak to the local women's club about ovarian cancer. Which sign or symptom of the disease is the most common?
- Abdominal bloating
- Vaginal bleeding
- Urinary tract infection
- Sharp thoracic pain
Correct answer: Abdominal bloating
Ovarian cancer occurs more frequently in women over age 50. The disease has vague early symptoms that are often ignored. One of the primary signs is abdominal bloating. The woman may feel it, and it may look like a swollen belly to others. A woman may feel full after eating just a few bites. She may also experience indigestion or nausea. The other options are not related to ovarian cancer.
- After witnessing a motor vehicle crash, the nurse stops to offer emergency assistance. One victim was thrown from his vehicle. Which finding indicates he may have sustained serious head trauma?
- The victim is reluctant to move his limbs
- The victim states he has a very bad headache
- He asks the nurse, "What happened?"
- He has clear fluid draining from his ears
Correct answer: He has clear fluid draining from his ears
When clear cerebrospinal fluid leaks from an ear or the nose, it indicates a tear in the dura, the outermost layer of the meninges. This requires immediate evaluation and treatment. The other options are significant findings and need attention, but they are not as urgent as the fluid draining from the victim's ears.
- Which opportunistic disease is an HIV/AIDS client at risk for?
- Fibroblastic sarcoma
- Ewing sarcoma
- Synovial sarcoma
- Kaposi sarcoma
Correct answer: Kaposi sarcoma
Kaposi sarcoma is an opportunistic disease that occurs as a result of immunosuppression. Organ transplant patients can be at risk as well. The other sarcomas do not have a known cause. Ewing sarcoma is a type of bone cancer that is mostly diagnosed in teens and young adults. Synovial sarcoma begins in the cells around the joints and tendons, anywhere in the body. Fibroblastic sarcoma develops in the fibrous tissues, most commonly in the limbs, skin, and trunk of the body.
- Cirrhosis of the liver can promote prolonged bleeding. Which of the following should the nurse anticipate administering to counteract this complication?
- Vitamin E
- Vitamin K
- Vitamin C
- Vitamin A
Correct answer: Vitamin K
Vitamin K is a fat-soluble vitamin that is essential for clotting. The other vitamins do not directly affect the clotting process.
- In a normal sinus rhythm, what does the P wave of the electrocardiogram (ECG) indicate?
- Atrial depolarization
- Ventricular repolarization
- Ventricular depolarization
- AV node depolarization
Correct answer: Atrial depolarization
The P wave is the first electrical impulse in the cardiac cycle. It shows the atria depolarizing and contracting. The first electrical impulse for the heart is generated at the sinoatrial (SA) node, which then depolarizes the atrial cells and causes them to contract. This pushes the blood from the atria into the ventricles. The normal duration is less than 0.12 seconds.
- During a routine visit to the internal medicine clinic, a client tells the nurse that despite having little appetite, the client has gained 6 pounds (2.7 kg) during the past week. When performing a physical assessment, the nurse notes that the client has edema in the feet and ankles. Which of the following conditions is MOST likely to be the cause?
- Congestive heart failure
- Hyperthyroidism
- Cushing's syndrome
- Marfan syndrome
Correct answer: Congestive heart failure
The client's unexplained rapid weight gain is probably due to fluid retention. According to the American Heart Association, a weight gain of more than 2-3 pounds (lb) over 24 hours or 5 lb in a week could be a sign of heart failure. A lack of appetite or a sensation of being full is also a sign of worsening heart failure. Other signs and symptoms are fatigue, weakness, dyspnea, persistent cough with blood-tinged phlegm, and difficulty concentrating. Hypothyroidism, not hyperthyroidism, can lead to low body temperature, which causes fluid retention or bloating. Cushing's syndrome can cause weight gain, usually seen in the abdomen, neck, face, and upper back. Marfan syndrome is a connective tissue disorder, characterized by unusually long limbs.
- For a client scheduled for an angiogram, which of the following nursing considerations is correct?
- If the client has an iodine allergy, they should be administered an antihistamine
- If the client is over age 80, they will require more sedation and contrast dye
- The client should have a protein snack before the procedure
- If the client has renal dysfunction, they should receive limited fluids
Correct answer: If the client has an iodine allergy, they should be administered an antihistamine
An angiogram is used to evaluate specific areas of the arterial system by injecting a dye through a catheter at the femoral or radial artery. The dye will make the coronary arteries visible on fluoroscopy. Nursing considerations include the following: 1. Informed consent must be obtained. 2. Clients must be evaluated for a history of allergy to iodine or radiopaque dye. 3. If an allergy to iodone or dye exists, the client may be premedicated with an antihistamine. 4. Clients with impaired renal function are at an increased risk of further renal damage and may receive a large amount of IV fluids to flush out the contrast dye used during the procedure. Generally, clients are NPO 3-8 hours before the angiogram. Elderly clients have diminished organ function, making it harder to clear sedation and contrast dye from their systems.
- Alcohol, caffeine, and smoking are risk factors for which category?
- Psychosocial
- Genetic
- Physiological
- Environmental
Correct answer: Psychosocial
Psychosocial risk factors include lifestyle choices, such as the use or abuse of alcohol, caffeine, tobacco, and illicit drugs. Other risk factors include loneliness, grief, relationship problems, and work-related stress.
- The nurse is caring for a client diagnosed with mild cognitive impairment. Which of the following would be the most effective intervention for this client?
- Application of soft restraints
- Frequent reorientation
- Behavior modification
- Relaxation therapy
Correct answer: Frequent reorientation
For a client diagnosed with mild cognitive impairment, frequent reorientation is the most effective intervention. Behavior modification is an intervention aimed at changing undesirable behaviors. Restraints can increase agitation and should not be used unless absolutely necessary and only when certain criteria are met.
- Following extensive bloodwork, a client is informed that she has cancer. She tells the nurse, "I think these results are wrong. I ate lunch before the blood was drawn, so we should test again." The nurse knows the client is using which defense mechanism?
- Denial
- Rationalization
- Compensation
- Coping
Correct answer: Rationalization
Defense mechanisms soften the blow of bad news by changing reality. Rationalization helps a client explain information with faulty logic. Denial is refusal to accept facts. Compensation covers up a weakness by embellishing. Coping is a generic term.
- Which of the following activities can help residents in a nursing home to reminisce?
- Provide pet therapy
- Encourage storytelling
- Schedule a sing-along
- Offer exercise classes
Correct answer: Encourage storytelling
Reminiscing, or life review, is a positive way to help elderly clients remember and restructure their life experiences. It is a valuable tool for strengthening ego identity. The other three activities are good for socialization and physical activity.
- A nurse is working with parents whose newborn daughter has a congenital birth defect. Which psychosocial need for their child is most important for the parents to understand now?
- Hope
- Trust
- Autonomy
- Identity
Correct answer: Trust
According to Erickson, all infants from birth to 18 months must learn to feel secure in the world. When parents provide consistent care and stability, the baby learns to trust relationships. Regardless of this baby's medical situation, the need is the same. The other answer options are incorrect.
- An elderly client with Stage IV lung cancer has a DNR order. When the client's death appears imminent, what is the nurse's most appropriate action?
- Notify the client's funeral home
- Sit and hold the client's hand
- Start to gather the client's things
- Offer the client sips of herbal tea
Correct answer: Sit and hold the client's hand
No dying person should be left to die alone. Even with a DNR or Advance Directive that indicates no lifesaving measures should be taken, clients deserve comfort and caring at the end of life. The other answer options are incorrect.
- A 7-year-old girl with a diagnosis of leukemia is admitted for treatment. She asks the nurse, "Am I going to die?" What is the nurse's best response?
- Don't worry about that. Everyone here is helping you get better
- How are you feeling today? Tell me what you're thinking
- As soon as I finish with my other patients, I'll come back with a snack
- Let's talk about something cheerful. Want to watch television?
Correct answer: How are you feeling today? Tell me what you're thinking
Regardless of a patient's age, always give the patient an opportunity to talk and tell you what they are thinking. Being in a strange setting or undergoing a difficult treatment can make any client anxious. Therapeutic communication is essential.
- During the admission process of a male to the unit, he tells the nurse he is Jewish. How can the nurse determine if he follows Jewish Orthodox practices?
- Ask him about his dietary preferences
- Ask him if he was circumcised
- Ask him if he wears a yarmulke
- Ask him if he reads and speaks Hebrew
Correct answer: Ask him about his dietary preferences
The best way to determine how to respect a client's faith is to ask the client directly about dietary preferences and restrictions. Other branches of Judaism also wear yarmulkes, or skullcaps. Circumcision and speaking Hebrew are not limited to men of Jewish faith.
- A 45-year-old man with a traumatic brain injury (TBI) is a resident at a long-term care facility. When his injury causes periods of agitation, what is the most appropriate action?
- Take the resident to a private area to reinforce proper behavior
- Redirect him by tuning the TV to his favorite show
- Give the resident a new task to help calm his mood
- Show him familiar objects and pictures that he keeps in his room
Correct answer: Show him familiar objects and pictures that he keeps in his room
Showing the resident some objects he knows can reduce his agitation and anxiety. Clients with traumatic brain injuries (TBI) can display a variety of behaviors, depending on the location of the injury. It is important to know that TBI is not the same as dementia, and interventions may be different. Agitation and irritability are common, as well as anxiety. Explaining proper behavior is not helpful. Redirecting in the moment of agitation is not effective, and a new task can increase frustration.
- A 78-year-old client with a diagnosis of moderate Alzheimer's disease lives with her 50-year-old daughter and 22-year-old grandson. When the home health nurse visits, which statement by the grandson to the nurse indicates a need for more education about Alzheimer's?
- She calls me by my grandpa's name
- We had to install door latches up high
- She deliberately hides my favorite jacket
- I have to show her where her bedroom is
Correct answer: She deliberately hides my favorite jacket
People with Alzheimer's disease do not hide things to deliberately deceive. Hiding and hoarding can be a way for someone with Alzheimer's to have a sense of control. Persons with Alzheimer's disease may also have delusions and think that they must hide things to protect themselves. The other answer options are normal when caring for someone with the disease.
- During an admission intake to the Mental Health Unit, a client tells the nurse that she is Oprah Winfrey. The nurse knows that the client is experiencing
- An auditory hallucination
- A loose association
- A flight of imagination
- A delusion of grandeur
Correct answer: A delusion of grandeur
A delusion is a false personal belief that resists modification, even when presented with evidence to the contrary. A delusion of grandeur is the false belief in one's superiority, greatness, or intelligence. A hallucination is a false perception. Loose association is a way of thinking and speaking in which ideas are unrelated to each other. A flight of imagination (also called flight of fancy) is a creative idea or story that is false of impractical.
- You are discussing health issues with a client whose body mass index (BMI) is 31. Which statement by the client indicates the coping mechanism of rationalization?
- The problem is that my husband always buys ice cream
- You probably think I'm disgusting because I can't lose weight
- I know if I remain obese, I'll have many health risks
- My mother and aunts were fat, too. It's genetic, I'm sure
Correct answer: My mother and aunts were fat, too. It's genetic, I'm sure
Rationalization is making excuses or explaining a situation in a way that allows a person to avoid taking responsibility for an action or behavior. Acknowledging health risks and eating ice cream show insight. Accusing the nurse of judging the client is using projection as a coping mechanism.
- When teaching a mother how to bathe her newborn, the nurse instructs the mother to
- Just make sure the diaper area is clean and dry
- Start with the eyes, face, and neck of the baby
- Start with the baby's feet and wash upward
- Only use baby wipes for the first two weeks
Correct answer: Start with the eyes, face, and neck of the baby
Start with the eyes and face, which are the cleanest areas. A baby's neck can hold milk in the folds. Next are arms and hands, then legs and feet. The diaper area is washed last. The other answer options are incorrect.
- During a prenatal ultrasound, Tetralogy of Fallot is diagnosed. When the mother asks you what that means, the correct response is
- It means the baby will have hernias
- It's an unusual intestinal malformation
- It's a serious but treatable heart defect
- It means the baby will develop scoliosis
Correct answer: It's a serious but treatable heart defect
Tetralogy of Fallot is a congenital heart condition involving four abnormalities occurring together, including a defective septum between the ventricles and a narrowing of the pulmonary artery. It is treated with open-heart surgery soon after birth. The other responses are incorrect.
- During a home health visit, the client's spouse tells the nurse that the client's GERD is not resolving. After more questioning, the nurse recommends
- Placing the client in a supine position after each meal
- Putting 6-inch blocks under the legs of the head of the bed
- Switching the client to a full liquid diet
- Offering the client warm liquids every two hours (q2h) during the day
Correct answer: Putting 6-inch blocks under the legs of the head of the bed
Gastroesophageal reflux disease (GERD) can sometimes be relieved by simple changes. Elevating the head of the bed keeps the esophagus higher than the stomach. Do not use pillows because they can put pressure on the stomach. The other answer options are incorrect.
- A female teen client has iron-deficiency anemia. The nurse instructs her to take the prescribed oral iron supplement with
- Plain water
- Orange juice
- Whole milk
- Ginger ale
Correct answer: Orange juice
Of these four answer options, orange juice is the only one that has vitamin C (ascorbic acid), which aids iron absorption. Other foods high in vitamin C are also beneficial.
- Which of the following alterations in sensory function is normal for an elderly client?
- Decreased sensitivity to bright light
- Increased sound discrimination
- Decreased chronic pain perception
- Increased ability to taste spices
Correct answer: Decreased chronic pain perception
As people age, the perception and reporting of chronic pain decreases after the seventh decade. Studies show that many elderly people believe that chronic pain is a natural part of aging, and they consider pain less serious than other life events, such as loss of a spouse or independence. Acute pain remains consistent across all age groups. In general, the aging process causes the sense of taste to diminish because of reduction in the number of taste buds and shrinkage of those that remain. The sense of smell also decreases, which compromises both smell and taste. Eyes become more sensitive to glare and harder to adapt to darkness. Hearing and balance are also affected because of changes in the auditory nerves.
- A 3-year-old boy is on the autism spectrum. Which behavior can the nurse tell his parents to expect from him?
- Indifference
- Curiosity
- Kindness
- Impatience
Correct answer: Indifference
Children with autism tend to show little or no ability to relate to other people, including their parents. Autism is categorized in three ways: 1. Inability to relate to others. 2. Inability to communicate with others. 3. Limited interests or activities.
- A client newly diagnosed with glomerulonephritis is starting a low-sodium diet. Which of the following meals is the best choice?
- Cheese pizza with a raised-dough crust
- Baked chicken breast with a salad
- Beef noodle soup with saltine crackers
- Hot dog without a bun and chips
Correct answer: Baked chicken breast with a salad
Of these four options, the best is baked chicken with a simple salad. Sodium is present in many foods, including broth, cheese, processed meats, and baked goods.
- A nurse is instructing a client with a head cold on how to use a nasal decongestant spray. Which statement is true about overuse of the spray?
- Your nasal passages will likely become very irritated
- Your stuffiness will feel worse if you use it too often
- You can expect to see bleeding from the mucous membranes
- Using nasal spray decreases the ability to fight the cold virus
Correct answer: Your stuffiness will feel worse if you use it too often
Overuse of decongestant sprays can cause rebound vasodilation, making the stuffiness feel worse. Decongestant sprays do not cause viral resistance or ulceration. Irritation and bleeding may result from frequent nose-blowing and wiping.
- During a routine prenatal visit, a client tells the nurse that she is experiencing heartburn. Which is the most appropriate measure to recommend to the client?
- Eliminate between-meat snacks
- Avoid all caffeinated beverages
- Drink more fluids with each meal
- Add more fatty foods to the diet
Correct answer: Avoid all caffeinated beverages
Coffee and tea contain caffeine, which can increase the risk of acid reflux and heartburn, so they should be avoided. Fatty foods and fluids with meals do the same, so increasing them can worsen the heartburn. Snacks and smaller meals are helpful and should be encouraged.
- The rehabilitation nurse is instructing a client who is ready to go home after a total hip replacement. Which statement by the client indicates a need for more education?
- I'll put a pillow between my knees when I'm in bed
- I know I can't drive my car for six more weeks
- I'll change my sitting position every three hours
- I’ll wear a surgical stocking on the other leg
Correct answer: I'll change my sitting position every three hours
For a client with a total hip replacement, sitting for more than one hour is not advisable. While awake, the client should stand and take a few steps every hour. It is extremely important to maintain blood circulation in the operative leg. The other answer options are all appropriate.
- When a client with Stage IV kidney cancer comes for his appointment, he tells the nurse that he has decided to stop treatment because of the financial and emotional costs. What is the nurse's most appropriate response?
- I absolutely believe you've made the best decision
- Surely your family is worth more than these concerns
- Please don't give up hope. I hope you will reconsider
- The palliative care and hospice program can tell you more
Correct answer: The palliative care and hospice program can tell you more
The most appropriate response supports the client's decision and provides information. Every client should be allowed to make their own healthcare decisions. Stage 4 metastatic kidney cancer patients have a five-year survival rate of just 10 percent.
- A nurse volunteers to help at her children's school health fair. She will hand out samples of hand sanitizer and provide information about avoiding the flu. What type of activity is this nurse engaged in?
- Community education
- Professional development
- School awareness
- Personal service
Correct answer: Community education
The nurse is participating in a community health activity by educating nonprofessionals about ways to stay healthy and avoid the flu. Community education can be formal, as in this example or in another setting. Informally, the nurse serves as a resource in the community.
- Which phase of the nursing process involves data collection and validation?
- Diagnosis
- Assessment
- Implementation
- Planning
Correct answer: Assessment
The nursing process is a 5-phase process that is systematic and client focused. In order, the steps are assessment, diagnosis, planning, implementation, and evaluation. Assessment requires both subjective and objective data collection. This first step can be viewed as the most important component of the nursing process.
- A home health nurse visits a client with terminal cancer. The client asks the nurse to witness the advance directive. What is the nurse's BEST action?
- Help the client find a third-party witness
- Notify the home health agency at once
- Agree to sign the directive as a witness
- Tell the client that it's no longer necessary
Correct answer: Help the client find a third-party witness
An advance directive states what the client wishes regarding the withdrawal of life support and life-prolonging measures, as well as who will make the decisions if the client is unable to. A nurse or other employee of a facility or organization that provides care cannot be a witness, because it would represent a conflict of interest. The witnesses must be two people unrelated to the client who sign the document as proof that the client signed the document authentically.
- A client wearing expensive jewelry reports for same-day surgery. What should the nurse tell the client?
- We'll ask the supervisor to hold your jewelry until you're in the recovery room
- We'll put the jewelry in an envelope. We'll both sign it and put it in our safe
- We'll tape the jewelry to you so it will remain secure during surgery
- We keep all expensive items in the narcotic box so no one will take them.
Correct answer: We'll put the jewelry in an envelope. We'll both sign it and put it in our safe
To ensure the safety of a client's valuables while the client is having a procedure, the nurse should list the items on an envelope, insert the valuables, and seal it. Then both the client and the nurse should sign it before placing the envelope in the safe.
- If a patient asks to see her chart, what should the nurse do?
- Report the patient's request to the charge nurse
- Call the doctor to get an order for the patient to read her chart
- Give the patient the chart and answer her questions
- Tell the patient she can see the chart when her physician is present
Correct answer: Give the patient the chart and answer her questions
The patient has a right to see her chart. As the patient's advocate, the nurse should answer all her questions and encourage the patient to become part of her healthcare team. The Patient's Bill of Rights has been in place since the 1960s. All patients should be aware of their rights.
- After a client has had major surgery, the nurse provides information about the client's condition to a visitor whom the nurse believes to be a family member. Later, the nurse finds out that the visitor was not a relative. Which legal violation has occurred?
- Responsibilities beyond the scope of practice
- Failure to follow the chain of command
- Negligence in providing appropriate care
- Disregard for client's right to privacy
Correct answer: Disregard for client's right to privacy
Providing information about a client's medical status without the client's permission violates the client's right to privacy and confidentiality. It also puts the nurse and the institution in legal jeopardy. The other answer options are incorrect.
- While passing medications, a nurse overhears another LPN verbally abusing a patient. What should the nurse do?
- Notify the unit charge nurse or supervisor
- Call the facility's security department
- Take the LPN aside and give the LPN a warning
- Document the incident in the patient's chart
Correct answer: Notify the unit charge nurse or supervisor
Nurses and all other healthcare providers are mandated by law to report witnessed or suspected abuse or neglect. Don't try to resolve the issue yourself. Follow the chain of command and report the incident to the charge nurse or nursing supervisor.
- An experienced nurse is precepting a new graduate on the unit. As she teaches the new nurse to prioritize assignments, which task requires intervention by the experienced nurse?
- Allowing time for unexpected events
- Making a list of supplies for each duty
- Documenting at the end of the shift
- Asking for assistance with organization
Correct answer: Documenting at the end of the shift
Documenting should take place throughout the shift. Making notes in a health record is an ongoing task. Charting only at the end of the shift is incorrect. Charting before giving care is illegal. The other tasks are appropriate for a new nurse.
- Nurses agree to be advocates for their clients. The practice of advocacy calls for the nurse to
- Seek out the nursing supervisor to resolve conflicts
- Assess the client's perspective and explain it when necessary
- Apply the law to the client's clinical condition
- Document all clinical changes in the medical record every two hours
Correct answer: Assess the client's perspective and explain it when necessary
Nurses always strive to assess and understand their patients. When a nurse can identify a patient's personal values and then accurately describe those values and defend the patient's point of view, the nurse can be a successful advocate.
- If a client cannot read or write, the nurse can read the consent form in front of two witnesses. What else should the nurse do?
- Allow the Risk Management Supervisor to sign the consent
- Ask the hospital lawyer to assist with the consent
- Let a family member sign the consent form
- Ask the patient to make an "X" as a signature
Correct answer: Ask the patient to make an "X" as a signature
The nurse can read the consent form in front of two witnesses, and the patient can sign in their presence. The patient must sign for himself unless the patient is a minor or not of sound mind. The nurse should never sign a consent form for a patient.
- Which of the following situations is considered an assault?
- A patient seeks to be discharged but is physically forced to remain
- A nurse threatens to put a resident in restraints
- The supervisor shares a nurse's poor evaluation at a staff meeting
- A doctor tells a client that the nurse is incompetent
Correct answer: A nurse threatens to put a resident in restraints
An assault is when one person makes another person fearful of harm. Battery is offensive touching or the use of force without the other person's permission. Defamation is sharing false information that harms another person's reputation.
- The following clients arrive for their appointments at the diabetic clinic. Whom should the nurse see first?
- A type 2 diabetes client who has a headache and a fruity odor on his breath
- A type 1 diabetes client who feels weak but is eating a simple-carb snack
- A type 1 diabetes client who needs a dressing change for his foot ulcer
- A type 2 diabetes client who is to receive education about her diet
Correct answer: A type 2 diabetes client who has a headache and a fruity odor on his breath
The client with a headache and fruity odor on his breath shows signs of entering diabetic ketoacidosis (DKA) and needs to be assessed immediately. The type 1 client with possible low blood sugar is already eating a snack and should be seen next.
- If a nurse posts comments or anecdotes on social media that include identifying information about clients, what are the grounds for firing the nurse?
- The nurse violated a pledge
- The nurse was unethical
- The nurse was negligent
- The nurse violated the law
Correct answer: The nurse violated the law
The nurse has violated the Health Insurance Portability and Accountability Act (HIPAA), which became a federal law in 1996. This law protects every patient's right to the privacy and confidentiality of all medical information, including written information, oral electronic information, and personal identity information.
- A 23-year-old with terminal brain cancer tells you that she has an Advance Directive for her end-of-life care. You know this can mean any of the following EXCEPT
- Her living will can indicate her wishes
- She can choose to be a DNR patient
- Her family can direct the staff to keep her alive
- She can designate who can make her medical decisions
Correct answer: Her family can direct the staff to keep her alive
Advance directives describe the kind of medical treatment you want for yourself if you are in serious health condition or unable to speak for yourself. Anyone over age 18 can have an advance directive. Once in place, it is a legal document that cannot be revoked. A person can choose to have a Living Will, which lists the person's wishes regarding end-of-life care. The person can also designate someone who can make medical decisions if the person is unable to; this is called a Medical Power of Attorney. A person can also indicate a wish to be a DNR, or Do Not Resuscitate, patient if the person's heart stops beating or the person stops breathing.
- What is the FIRST thing that a nurse should do in a fire emergency?
- Contain the fire
- Pull the fire alarm
- Evacuate the building
- Rescue patients in danger
Correct answer: Rescue patients in danger
The RACE acronym is used to prioritize and sequence the steps to follow if a fire occurs. R: Rescue patients. A: Pull the fire alarm. C: Contain the fire by closing doors, etc. E: Extinguish the fire with a fire extinguisher OR evacuate the building.
- What is the meaning of this symbol?
- Biohazard
- Radioactive
- Isolation
- Poison
Correct answer: Biohazard
The biohazard symbol is used in the labeling of biological materials that carry a significant health risk to living things, including viral samples and used hypodermic needles. The biohazard symbol is used internationally.
- After receiving the report from the previous shift, which assigned client should the nurse prioritize?
- The post-op client waiting for a chest x-ray
- The post-op client waiting for discharge teaching
- The post-op client who needs a dressing change
- The post-op client on O2 with dyspnea
Correct answer: The post-op client on O2 with dyspnea
The airway (the "A" in "ABC") is always the priority, so the client who is experiencing difficulty breathing must be attended to first.
- Following a stroke with left-sided weakness, a client is also diagnosed with hemianopia. Which intervention will be added to the client's care plan?
- Approach the client from the unaffected side
- Turn the client to the right side for visitors
- Use the "clock method" when serving meals
- Cover the affected eye during the day
Correct answer: Approach the client from the unaffected side
Hemianopia is a type of blindness in which the client is unable to see the right or left half of their field of vision. It may be temporary or permanent. To accommodate a client with hemianopia, it is best to approach the client from the unaffected eye so that the client can use their peripheral vision. The other answer options have no therapeutic value.
- A pediatrician's office notifies the hospital that a 7-year-old child will be admitted with a diagnosis of measles. Which precautions should the nurse prepare for?
- Reverse
- Droplet
- Enteric
- Airborne
Correct answer: Airborne
Precautions for measles include BOTH airborne and contact. Airborne precautions are used for diseases spread through the air, such as measles, tuberculosis, and chickenpox. Contact precautions are for diseases spread by touching the person or items in the room: MRSA, VRE, diarrheal illnesses, and open wounds. Measles is so contagious that breathing the air or touching a contaminated surface can infect up to 90% of people who are not immune. Droplet precautions are for pathogens spread by coughing and sneezing, such as pneumonia, influenza, and bacterial meningitis.
- A male patient undergoing chemotherapy develops white lesions on his tongue and inner cheeks. The nurse knows the condition is likely
- Alphthous ulcers
- Candidiasis
- Leukoplakia
- Herpes simplex
Correct answer: Candidiasis
Oral candidiasis can occur in patients with weakened immune systems, such as patients receiving chemotherapy. It is characterized by white spots on the oral mucosa that cannot be scraped off without bleeding. Do not attempt to remove these spots. Herpes simplex is marked by tingling and burning of the lips and mouth areas as well as blisters and a sore throat Aphthous ulcers, or canker sores, are sore oral lesions. Oral leukoplakia leads to thickened, white patches on the cheeks, tongue, lower lip, or floor of the mouth.
- A new resident at a long-term care facility has been diagnosed with herpes zoster. Which staff member should NOT be assigned to care for the resident?
- A staff member who never had diphtheria or vaccination to prevent it
- A staff member who never had chickenpox or vaccination to prevent it
- A staff member who never had measles or vaccination to prevent it
- A staff member who never had mumps or vaccination to prevent it
Correct answer: A staff member who never had chickenpox or vaccination to prevent it
Varicella zoster is the same virus that causes both chickenpox and herpes zoster (shingles). People who haven't had either chickenpox or the varicella vaccine should not be exposed to the virus. The other diseases are not associated with herpes zoster.
- Which client has the highest risk of falling?
- A 22-year-old male with 3 fractured ribs and his right arm in a cast
- A 36-year-old female with a fractured tibia
- A 63-year-old male with angina pectoris
- A 75-year-old female with episodes of syncope
Correct answer: A 75-year-old female with episodes of syncope
Because of age and unexpected syncope, the 75-year-old female is at the greatest risk of falling. The nurse should observe the client's balance and gait; the client may require assistance when ambulating, even when going to the bathroom.
- The nurse administers a dose of vitamin B12 to the wrong patient. What is the appropriate action for this medication error?
- Contact the pharmacy to request an antidote
- No action is necessary, because vitamin B12 is harmless
- Document the error in the medication record
- Notify the doctor and fill out an incident report
Correct answer: Notify the doctor and fill out an incident report
Any medication error must be reported to the ordering physician, and an incident report must be completed. A medication given to another patient must also be recorded on that patient's chart, without mentioning that it was an error. The nurse should follow the hospital's or facility's policy. Vitamin B12 is a nutrient that keeps nerve and blood cells healthy and helps make DNA.
- A nurse is invited to speak to a high school sophomore health class about transmitting infectious mononucleosis. Which of the following statements has the most accurate information for the class?
- Avoid holding hands or intimate touching
- Remember to wash your hands frequently
- Don't share food or drinks with others
- You'll know if you have it a week later
Correct answer: Don't share food or drinks with others
Infectious mononucleosis is a viral disease that is easily spread when saliva is shared by cups, straws, eating utensils, items that have been in the mouth, and kissing, Caused by the EpsteinBarr virus, it is most common among 15- to 25-year-olds. Handwashing is always important, but the Epstein-Barr virus is not transmitted on the hands. Contact, other than orally, does not spread the disease. The incubation period is 30-45 days.
- During an initial assessment of a new female resident in a long-term care facility, the nurse observes old and recent bruises on the arms, back, and buttocks of the woman. She tells the nurse that her family members hit her. What is the nurse's best response?
- We can teach you how to defend yourself from abuse
- You're safe now. I won't tell anyone what you said
- I'll tell the nursing supervisor to limit family visits
- I have a legal responsibility to report what I know
Correct answer: I have a legal responsibility to report what I know
Even if a client asks for confidentiality, all health providers are legally obligated to report suspected abuse of any client regardless of the client's age. Teaching a client self-defense is not realistic. Limiting family visits could lead to further abuse.
- What is the single most effective action that a nurse can perform to avoid spreading an infection?
- Practice principles of asepsis
- Adhere to proper hand hygiene
- Use personal protective equipment
- Follow standard precautions
Correct answer: Adhere to proper hand hygiene
Handwashing is the single most important action that nurses - and anyone else - can perform to prevent spreading infection. The other options are also important and useful, but handwashing is essential.
- A client receiving chemotherapy is experiencing stomatitis. What should the nurse offer the client?
- Warm saline rinses four times each day
- Plenty of ice chips between meals
- Vigorous oral care with a commercial mouthwash
- Hot soup for lunch and dinner
Correct answer: Warm saline rinses four times each day
Stomatitis is irritation of the lips, mouth, tongue, and oropharynx, which occurs when chemotherapy kills healthy cells that are rapidly dividing. It can impair nutrition, speech, sleep, and the quality of life. Warm saline rinses are non-irritating and help eliminate bacteria that can cause infection. Other nursing interventions include gentle oral hygiene and administration of a topical analgesic as ordered by the physician.
- A client with Stage III lung cancer reports that he has nausea and loss of appetite caused by the chemotherapy. What should the nurse recommend to promote adequate nutrition?
- Eat only your favorite foods
- Eat small meals throughout the day
- Eat only when you feel hungry
- Eat a single large meal for lunch
Correct answer: Eat small meals throughout the day
Encouraging the patient to small meals frequently throughout the day can help avoid nutritional deficiencies and improve the patient's quality of life. The patient may not feel hungry because of chemotherapy-induced nausea, but they should be encouraged to eat even if not hungry.
- A patient diagnosed with Crohn's disease has a new colostomy. When assessing the patient's stoma, which of these would alert the nurse that the stoma has retracted?
- Pinkish red and moist
- Narrowed and flattened
- Concave and bowl shaped
- Dry and reddish purple
Correct answer: Concave and bowl shaped
A colostomy is created when the bowel is pulled through an opening in the abdominal wall, creating a stoma through which intestinal contents will pass. A healthy stoma will protrude about 2.5 cm with an open lumen at the top. The stoma should appear pinkish red and moist. A dry, dusky, or reddish-purple stoma indicates ischemia. A narrowed, flattened, or constricted stoma indicates stenosis. A concave and bowl-shaped stoma has retracted. A retracted stoma can be difficult to care for. Complications include problems maintaining appliance placement, leading to leakage and sore skin.
- When providing postmortem care for a patient who will be an eye donor, which action is most appropriate?
- Tape the eyes tightly and place the patient in a high Fowler's position
- Close the eyes and place the patient in a supine position
- Cover the eyes with saline-soaked pads and place the patient in a low Fowler's position
- Apply silver nitrate to the eyes and place the patient in a Trendelenburg position
Correct answer: Cover the eyes with saline-soaked pads and place the patient in a low Fowler's position
When preparing a deceased patient for eye or corneal donation, close the eyes and cover them with soaked gauze pads to keep them moist. Apply a small ice pack to the eyes, if possible. Elevating the head of the bed will help the eyes remain closed.
- The nurse is preparing a patient for a total colectomy and the placement of an ileostomy. The patient asks where the stoma will be located. The nurse identifies which of the following areas as the correct stoma site?
Correct answer: C
A total colectomy involves the removal of the large intestine. The gastrointestinal output will occur at the terminal end of the ileum. The stoma will be located in the right lower quadrant of the abdomen. A total colectomy is performed for intestinal inflammatory conditions such as Crohn's disease or ulcerative colitis. It may also be done for severe chronic constipation.
- After their 12-year-old daughter is prescribed a brace for her scoliosis, the nurse provides instruction to the parents. Which statement by the mother indicates a need for more education?
- It's important for her to stay active and do the prescribed exercises
- She should wear a soft T-shirt with no side seams under the brace
- The brace should be worn as snugly as possible
- I'll put lotion on her skin before she puts on the brace
Correct answer: I'll put lotion on her skin before she puts on the brace
Lotions, creams, and powders can soften the skin, making it more susceptible to breakdown. The T-shirt and brace should fit snugly to avoid rubbing and irritating the skin. The girl can stay active and perform specific exercises recommended by a physical therapist.
- A nurse is administering an enema solution to a client. The client tells the nurse that he feels pain and cramping in his abdomen. What is the nurse's BEST action?
- Discontinue the enema and notify the physician
- Pause for 1 minute, then restart slower
- Explain that an enema can cause discomfort
- Quickly administer the rest of the solution
Correct answer: Pause for 1 minute, then restart slower
Abdominal pain and cramping can occur when the enema solution is administered too quickly. The nurse should stop for a minute and then restart at a slower rate. The other answer options are incorrect.
- For a client with a surgical wound, which of the following meals will best promote healing?
- Spaghetti with marinara sauce, pudding, and a glass of wine
- Roast chicken, broccoli, cantaloupe, and a glass of milk
- Spinach salad, buttered roll, gelatin, and coffee with cream
- Hamburger, french fries, apple pie, and a large soft drink
Correct answer: Roast chicken, broccoli, cantaloupe, and a glass of milk
To promote wound healing, clients need more calories, protein, and vitamins A and C. The meal with chicken, broccoli, cantaloupe, and milk has the most nutrients required for healing. The other meals have some of the required nutrients but also include items that have no nutritional value.
- A client receiving chemotherapy has a poor appetite, so a liquid nutritional supplement is recommended. What is the BEST time for the client to drink the supplement?
- Between breakfast and lunch
- Along with lunch
- Right before lunch
- Right after lunch
Correct answer: Between breakfast and lunch
Supplements should not replace meals, so they are given between meals. If a supplement is given prior to a meal, it can suppress the client's appetite. If a supplement is given immediately after a meal, the client may be too full to finish the supplement.
- During the admission process, a client tells the nurse that he is lacto-vegetarian. The nurse knows that this means he cannot eat
Correct answer: Eggs
Lacto-vegetarians can eat dairy products, soy, fruits, vegetables, lentils, grains, nuts, and healthy fats. They do not eat eggs, poultry, fish, or meat.
- Following abdominal surgery, a client tells the nurse that he can't follow post-op instructions on coughing because of pain at the incision site. Which of the following is the BEST way to help reduce the client's discomfort?
- Sit at the edge of the bed before he coughs
- Administer pain medication after the client coughs
- Hold a pillow on the incision while coughing
- Flex both knees to the chest when coughing
Correct answer: Hold a pillow on the incision while coughing
To reduce pain while performing post-operative coughing, use a pillow and apply light pressure at the incision site. Flexing knees or sitting up are not as effective as using the pillow as a splint. Pain medication should be given before the client tries to cough.
- A pediatric patient has been admitted to the unit with a diagnosis of right lower lobe (RLL) pneumonia. When auscultating the RLL, which sound should the nurse expect to hear?
- Stridor
- Wheezes
- Crackles
- Rhonchi
Correct answer: Crackles
Crackles would most likely be heard because this would indicate fluid in the airspace. Fluid in the airspace is consistent with pneumonia. Wheezes indicate a narrowing of the airways. Stridor is an emergency lung sound that is seen in airway constriction that can lead to complete closure. Rhonchi is heard in mixed-issue airway constriction and secretions.
- If a diabetic patient receives NPH insulin at 6:00 a.m., how soon might the patient show any signs of hypoglycemia?
- 9:00 a.m.
- 8:00 a.m.
- 7:00 AM
- 10:00 a.m.
Correct answer: 10:00 a.m.
NPH insulin is an intermediate-acting insulin, usually given once or twice a day. The peak effect of NPH insulin occurs 4-12 hours after administration, so the nurse should start to monitor for signs of hypoglycemia at 10:00 a.m. Hypoglycemia (blood glucose below 70 mg/dL) can have a rapid onset. Signs include shakiness, dizziness, anxiety, confusion, sweating, chills, and clammy skin. The patient's pulse may increase. The patient may complain of blurred vision, headache, fatigue, hunger, or nausea.
- A neighbor complains to the nurse that her doctor refuses to prescribe an antibiotic to treat her head cold. How should the nurse respond?
- Antibiotics don't work against any viral infections
- Only people who have chronic illnesses get antibiotics
- Antibiotics can only prevent you from being contagious
- Once your cold starts, antibiotics are ineffective
Correct answer: Antibiotics don't work against any viral infections
The common cold is a viral infection of the throat and nasal passages. Antibiotics are used to treat bacterial infections. Taking antibiotics can increase bacterial resistance that can make future courses of antibiotics ineffective.
- A client with a diagnosis of Parkinson's disease is starting on levodopa (Dopar) medication. The nurse tells the client that they will start experiencing the anticipated results in
- 2-3 weeks
- 1 week
- 4-5 weeks
- 6 weeks
Correct answer: 2-3 weeks
Parkinson's disease is a degenerative neurological disorder caused by the lack of dopamine. After starting levodopa therapy, it is important for clients not to expect improvements for about 2-3 weeks so that they will remain compliant with the drug regimen.
- A post-op patient with a PRN order for pain medication asks for a dose. After the nurse gets the codeine pill from the medication system, the patient states he'll save it until later. What is the nurse's most appropriate action?
- Dispose of the pill according to protocol
- Return the pill to the medication system
- Leave the pill in a cup at the patient's bedside
- Put the pill aside until the patient requests it
Correct answer: Dispose of the pill according to protocol
Once a controlled drug leaves the system, it must be administered or discarded according to hospital protocol. It must be made "irretrievable." The usual procedure is to dispose of the medication with two witnesses who are licensed to administer medications. They must observe the disposal and sign a log or document verifying the action. The other answer options are illegal.
- The doctor orders Zofran 8 mg PO t.i.d. The pharmacy sends a 100 ml bottle, labeled 4 mg/tsp. How many mL should be given for each dose?
Correct answer: 10 mL
1 tsp = 5 mL and contains 4 mg. Multiply by 2 to reach the ordered dose of 8 mg: 4 mg×2=8 mg. It will take 10 mL (2 tsp) to give 8 mg of Zofran.
- An 18-year-old male receives a prescription for tetracycline to treat his acne. The nurse advises him to avoid
- Sun exposure
- Chlorine pools
- Processed foods
- Contact sports
Correct answer: Sun exposure
Tetracycline can cause photosensitivity, which can damage skin. It should be taken with water one hour before or two hours after meals. Milk and other dairy products can decrease absorption of tetracycline. Children under 8 years of age should not take tetracycline.
- A home health nurse is teaching the spouse of a client to give the client digoxin tablets every day. The client should receive 0.25 mg PO qd. The medication bottle is labeled "Digoxin 0.125 mg Tablets." How many tablets should the client receive in each dose?
- 2 tablets
- 3 tablets
- 5 tablets
- 1/2 tablet
Correct answer: 2 tablets
Divide the desired dose by the available dose: 0.125 mg0.25 mg=2 tablets. Two tablets are required for each prescribed dose.
- After an argument with her mother, an adolescent female takes an overdose of Tylenol (acetaminophen). The nurse knows to watch for complications in which organ?
Correct answer: Liver
The liver is the primary site for acetaminophen metabolism. The drug undergoes sulphation (binding to sulphate molecules) and glucuronidation (binding to glucuronide molecules) before it is eliminated from the body. An overdose stresses the glucuronidation process, forcing the drug to be passed to another pathway (cytochrome P450), which forms a toxic metabolite called NAPQI. As NAPQI accumulates, it causes liver damage and possible liver failure.
- After the nurse instructs a client diagnosed with Clostridium difficile-associated diarrhea (CDAD), which statement by the client indicates the need for further teaching?
- The acid-reducing medications that I'm taking will help get rid of the C. diff.
- I should drink plenty of fluids while I'm being treated for this infection
- It's possible for the bacteria to live on surfaces like my bedside table for months
- After I go to the bathroom, I'll use soap and water instead of alcohol-based handrubs
Correct answer: The acid-reducing medications that I'm taking will help get rid of the C. diff.
Acid-reducing medications, prescribed for heartburn and gastroesophageal reflux, are actually associated with an increased risk of CDAD. Outside the body, C. difficile forms spores, which are resistant to alcohol-based handrubs and can live in the environment for many months. Fluids are necessary because the diarrhea is watery and fluid volume needs to be maintained.
- A newly-diagnosed client with Type 1 diabetes (T1D) is learning to self-administer insulin. The client asks why it's important to rotate injection sites. The nurse explains the reason is to prevent
- Poor absorption
- Insulin tolerance
- Increased pain
- Tissue scarring
Correct answer: Poor absorption
When insulin is injected into the same site more than once, fat deposits are formed that can cause poor or uneven absorption of the insulin. This is called lipodystrophy. Tissue scarring does not occur in the fat layers. Insulin tolerance and increased pain are incorrect answers.
- A type 2 diabetic is admitted into the medical-surgical unit with a diagnosis of pneumonia. The client's usual oral diabetes medication has been discontinued, and insulin SQ will be administered for glucose control. Why has this change been made?
- The client will require insulin injections from now on
- Acute illnesses can cause increased insulin resistance
- Insulin prevents hypoglycemia during an illness
- Infections increase the risk of hyperglycemia
Correct answer: Infections increase the risk of hyperglycemia
Infections, such as pneumonia, cause the body to respond to the stress by releasing stress hormones, such as glucocorticoids and epinephrine. Glucocorticoids and epinephrine increase blood glucose levels. Type 2 diabetics may temporarily require insulin during acute illnesses and hospitalizations, but they often return to their normal drug regimen after they recover.
- When a client with a chronic condition requires increasing doses of medication for their pain control, what is the likely cause?
- Cravings
- Addiction
- Tolerance
- Side effects
Correct answer: Tolerance
Clients with chronic pain often develop a tolerance to their medications. Increasing doses are necessary to achieve the same amount of relief as when the drug was originally prescribed. The other options are incorrect.
- A patient's physician orders Amoxil 500 mg PO bid. The pharmacy sends 250 mg tablets. How many tablets should the nurse administer for a single dose?
- 2 tablets
- 4 tablets
- 1/2 tablet
- 1 tablet
Correct answer: 2 tablets
Each tablet is 250 mg, so it will take two tablets to administer 500 mg as ordered: 250 mg500 mg=2 tablets.
- The nurse prepares a patient for insertion of a nasogastric (NG) tube by placing the patient in which position?
- Semi-Fowler's
- High Fowler's
- Sims'
- Supine
Correct answer: High Fowler's
Inserting a nasogastric (NG) tube carries a risk of aspiration if the patient vomits. The High Fowler's position keeps the head elevated to reduce the risk and facilitate the insertion of the NG tube.
- A cast is applied to a client's broken leg. A few hours later, the client starts to complain of severe pain and a feeling of pressure. The nurse suspects the client is experiencing
- Acute neuropathy
- Inflammatory myopathy
- Compartment syndrome
- Angelman syndrome
Correct answer: Compartment syndrome
Compartment syndrome occurs when excessive pressure builds up inside an enclosed muscle space in the body. Compartment syndrome usually results from bleeding or swelling after an injury. The dangerously high pressure in compartment syndrome impedes the flow of blood to and from the affected tissues. About 75% of acute compartment syndrome cases are the result of a broken leg or arm. Angelman syndrome is a genetic disorder. Inflammatory myopathy is usually associated with autoimmune disorders. Neuropathy is a nerve condition that causes numbness or weakness.
- After a client starts on a new medication for his hypertension, he returns to the office for follow-up. When supine, his blood pressure is 112/70, with a heart rate of 80. When he sits up, the nurse checks his B/P and HR again. Which of the following would indicate he is experiencing orthostatic hypotension?
- B/P 88/62, HR 100
- B/P-90/60, HR 68
- B/P 100/66, HR 90
- B/P 120/84, HR 82
Correct answer: B/P 88/62, HR 100
Orthostatic or postural hypotension results when the patient's blood pressure is not maintained during position changes i.e., from lying to either sitting or standing). Orthostatic hypotension is defined as a decrease of more than 20 mmHg systolic or more than 10 mmHg diastolic and a 10-20% increase in heart rate.
- A nurse is instructing a newly diagnosed client on diabetic foot care. Which statement by the client indicates that further education is needed?
- I’ll see a podiatrist for foot care
- I'll inspect my feet every day
- I'll wear clean, dry cotton socks
- I'll use lotion between my toes
Correct answer: I'll use lotion between my toes
Diabetics must pay careful attention to their feet. Because of neuropathy and impaired circulation, even a small cut can be dangerous. Lotion may be used on the feet, but to avoid fungal infections, it should never be used between the toes. The feet should be kept clean and dry at all times. Only cotton or wool socks should be worn.
- In a neurological assessment, what does "PERLA" stand for?
- Pupils Easily Respond to Latent Acuity
- Patient's Eyes Reactive with Light Association
- Pupils Equally Reactive to Light and Accommodation
- Patient's Eyes Round and Light Accessible
Correct answer: Pupils Equally Reactive to Light and Accommodation
The acronym “PERLA" stands for Pupils Equally Reactive to Light and Accommodation. Accommodation refers to your eyes ability to see things that are both close up and far away. The other options are incorrect.
- A nurse is working in an outpatient radiology clinic. The nurse is instructing a cancer patient who is receiving external radiation treatments. Which statement by the patient indicates a need for further education?
- I’ll stay out of the sun
- I'll take hot showers
- I’ll moisturize my skin
- I'll wear loose clothing
Correct answer: I'll take hot showers
External radiation therapy can cause the skin that is receiving the radiation to become dry and itchy, and peel. The skin may appear sunburned and swollen. Special care is necessary to avoid further irritation or permanent damage. Showers or baths should be short, in lukewarm water. The patient must protect the skin from sun exposure. Loose clothing prevents rubbing against the radiated areas. Moisturizing with approved products helps relieve dry, itchy skin that could progress to infection.
- The nurse is reviewing the laboratory reports of a patient admitted to the medical unit for observation. Which of these assessment findings requires immediate intervention?
- Serum magnesium level of 3.5 mEq/L (1.75 mmol/L)
- Blood urea nitrogen (BUN) level of 28 mg/dL (99.9 mmol/L)
- Serum potassium level of 4.5 mEq/L4.5 mmol/L)
- An International Normalized Ratio (INR) of 0.9
Correct answer: Serum magnesium level of 3.5 mEq/L (1.75 mmol/L)
This patient's magnesium level is elevated. (The normal range is 1.5-2.5 mEq/L.) Of these four answer options, hypermagnesemia will have the most serious consequences. The consequences of elevated magnesium include respiratory depression and heart block. The patient's BUN level is also elevated. (The normal range is 7-22 mmol/L.) The patient will need an evaluation, but this is not as critical as treating the hypermagnesemia. The potassium level is within the normal range of 3.5-5.0 mEq/L. The INR is within the normal range of 1.1 or lower.
- A client with a diagnosis of heart failure takes furosemide (Lasix). Her blood work shows her potassium level is 3.1 mEq/L. Which question to the client will BEST help the nurse assess the client's symptoms?
- Have you noticed that your speech is slurred?
- Have you had a sudden weight gain?
- Have you noticed a slower pulse rate?
- Have you had any leg cramps recently?
Correct answer: Have you had any leg cramps recently?
Normal potassium levels are 3.5 to 5.0 mEq/L. Potassium levels below 3.5 mEq/L indicate hypokalemia. The nurse should observe the client for muscle weakness, leg cramps, shortness of breath, irregular heart rhythms, depression, confusion, and lethargy. Elevated sodium levels (hypernatremia) result in rapid weight gain. Low phosphate levels (hypophosphatemia) can cause slurred speech.
- While making the initial rounds on her assigned patients, the nurse observes that one patient's peripheral intravenous (IV) site is pale, swollen, and cool to the touch. The infusion has stopped. The nurse reports these findings to the RN, suspecting that the cause is
- Phlebitis
- Infiltration
- Thrombosis
- Extravasation
Correct answer: Infiltration
Infiltration occurs when IV fluid or medications leak into the surrounding tissue. Extravasation is the leaking of vesicant drugs into the surrounding tissue. Extravasation can cause severe local tissue damage, including blistering and necrosis, so the drugs are rarely administered peripherally. Phlebitis is inflammation of a vein. Phlebitis appears reddened and feels warm to the touch. Thrombosis is a clot in a vein. Thrombosis feels warm and causes swelling and pain.
- Which of the following individuals is at the LOWEST risk of developing pneumonitis?
- 37-year-old housekeeper
- 40-year-old yoga instructor
- 22-year-old poultry handler
- 57-year-old corn farmer
Correct answer: 40-year-old yoga instructor
Pneumonitis is an inflammation of the walls of the alveoli in the lungs, usually caused by airborne irritants from a job or hobby. Difficulty breathing, often accompanied by a dry (nonproductive) cough, is the most common symptom of pneumonitis. Yoga instructors are at the lowest risk of being exposed to irritating materials. Corn farmers, poultry handlers, and housekeepers all work with and around substances that can be very irritating to the lungs.
- A patient is prescribed a new medication for the treatment of hypertension. While supine, the patient's blood pressure is 112/70 mmHg and the patient's heart rate is 80/min. The healthcare provider assesses the patient when the patient changes to a sitting position. Which of the following would indicate that the patient is experiencing orthostatic hypotension?
- BP 100/66, HR 90
- BP 120/84, HR 82
- BP 90/60, HR 68
- BP 88/60, HR 100
Correct answer: BP 88/60, HR 100
Orthostatic, or postural, hypotension is defined as a decrease of more than 20 mmHg systolic or more than 10 mmHg diastolic and a 10-20% increase in heart rate. It results when the patient's blood pressure is not maintained during position changes (i.e., from lying to either sitting or standing).
- The Emergency Department nurse is caring for an 88-year-old male transported from a nursing home. When lab results become available, which value should the nurse immediately report?
- Chloride (CI) 99 mEq/L
- Calcium (Ca) 9.4 mg/dL
- Potassium (K) 4.2 mEq/L
- Sodium (Na) 118 mEq/L
Correct answer: Sodium (Na) 118 mEq/L
The normal range for sodium (Na) is 135-145 mEq/L. A level below 120 is critical and can lead to death if not treated promptly. The normal ranges for the other electrolytes are as follows: Chloride (CI) is 97-107 mEq/L; calcium (Ca) is 8.6-10.2 mg/dL; and potassium (K) is 3.5-5.0 mEq/L.
- During a discussion about hypertension, the nurse teaches a client and her spouse about the signs and symptoms of a stroke. Which of the following best describes what they should watch for?
- Weakness and pitting edema
- Facial droop and slurred speech
- Sudden diaphoresis and jaw pain
- Indigestion and shortness of breath
Correct answer: Facial droop and slurred speech
Facial droop and slurred speech are clear signs of a stroke. Teach clients to remember "F.A.S.T." FAST is an acronym used as a mnemonic to help detect a stroke and enhance responsiveness to the needs of the person having a stroke. The acronym stands for Facial drooping, Arm weakness, Speech difficulties, and Time to call emergency services.
- As soon as the morning shift starts, a CNA reports to the nurse that a resident with diabetes has a glucose level of 50. The nurse assesses the client and finds him confused, cold, and clammy. What is the FIRST thing the nurse should do?
- Give the resident 4 ounces of fruit juice
- Call Emergency Medical Services
- Keep the resident NPO until he's stable
- Recalibrate the glucometer
Correct answer: Give the resident 4 ounces of fruit juice
Hypoglycemia is a glucose level below 70. Signs and symptoms include confusion, anxiety, feeling shaky, chills, clammy skin, fast pulse, dizziness, hunger, nausea, and feeling weak. Take immediate action by following the "15-15 Rule": Give the person a fast-acting carbohydrate, such as orange juice, a gel tube, one tablespoon of sugar or honey, or hard candy. Check the glucose level again in 15 minutes. Repeat until the glucose level is above 70.
- Which of the following is a consequence of immobility or extended bed rest?
- Loss of bone calcium
- Heightened reflexes
- Frequent urination
- Increased lung capacity
Correct answer: Loss of bone calcium
One of the consequences of immobility is loss of calcium from the bones, caused by the lack of weight-bearing activity. Other consequences include muscle weakness and atrophy, pneumonia, urinary retention, urinary tract infections, stiff joints, blood clots, and pressure sores.
- During an interview with a client diagnosed with Parkinson's disease (PD), which of the following speech patterns will the nurse anticipate?
- Pressured and hurried
- Clear and rhythmic
- Bubbly and spirited
- Slow, slurred, and monotone
Correct answer: Slow, slurred, and monotone
The neuromuscular effects of Parkinson's disease (PD) often involve the face, mouth, and throat, which can impair speech and tone of voice. The nurse should expect slowed, often monotone speaking patterns and difficulty articulating clearly. Pressured and hurried speech is characteristic of clients with hyperthyroidism. Clear and rhythmic fluency is an expected finding in a patient with normal speech patterns.
- The nurse is educating a client who will be starting peritoneal dialysis. How much time does a complete exchange cycle of infusion, dwell, and drainage, typically require?
- 30-45 minutes
- 90-120 minutes
- 60-90 minutes
- 15-60 minutes
Correct answer: 30-45 minutes
A client who receives peritoneal dialysis can expect a typical exchange cycle to last 30-45 minutes, using 2-3 liters of dialysate solution. There are three phases: infusion (5-10 minutes), dwell time (10 minutes), and drainage (10-30 minutes). During an exchange, the client can read, talk, watch television, or sleep. The solution can remain in the abdomen for a dwell time of 4-6 hours or longer. These are typical times, the actual number of cycles and the dwell times will vary by client.
- When assessing a client with a 12-year history of emphysema, what change can the nurse expect to find?
- Clubbing of the fingers
- Loss of body hair
- Tendency to gain weight
- Less mucus production
Correct answer: Clubbing of the fingers
Clubbing of the fingers, in which the distal phalanx of each finger is rounded and bulbous, is found in patients with chronic lung disease and hypoxia. Emphysema causes increased mucus production. Clients with emphysema tend to have a reduced appetite and weight loss. Loss of body hair is incorrect.
- A client calls the clinic to report the presence of loose stools. Which question should the nurse ask FIRST?
- Do you think you may have caught a bug during a recent trip?
- Could you describe the number and appearance of your stools?
- How much fluid are you drinking in a 24-hour period?
- Have you been taking antibiotics for treating an infection?
Correct answer: Could you describe the number and appearance of your stools?
Asking the patient to describe the stools (such as their frequency, consistency, color, and timing) will give the healthcare provider a basis for further assessment. The patient may also be asked about recent travel, use of antibiotics, and fluid intake.
- Which diagnosis is LEAST likely to carry a risk of third spacing?
- Diabetes mellitus
- Septic shock
- Hepatic cirrhosis
- Renal failure
Correct answer: Diabetes mellitus
Diabetes mellitus does not cause third spacing. Third spacing occurs when too much fluid moves from the intravascular space (blood vessels) into the interstitial or "third" space - the nonfunctional area between cells. This can cause edema and hypotension. Common sites are the abdomen, pleural cavity, and peritoneal cavity.
- When teaching a 36-year-old male with a new diagnosis of hepatitis C, which statement by the client indicates he needs further instruction?
- I'll take Tylenol when I get a headache
- From now on, I'll use a condom every time I have sex
- I need to get vaccinated for hepatitis A and hepatitis B
- I can't drink wine, beer, or other alcohol anymore
Correct answer: I'll take Tylenol when I get a headache
Inflammation caused by the hepatitis C virus can lead to cirrhosis or liver cancer, so the patient should take steps to avoid further damage to the liver. People infected with the hepatitis C virus should avoid alcohol and acetaminophen (Tylenol). They should also get vaccinated for hepatitis A and B. Barrier protection should be used during sex, but casual household contact is not a risk factor for transmission.
- As a nurse assesses a client with osteoarthritis (OA), what sign can the nurse expect to find?
- Bilateral joint swelling
- Stooped posture
- Joint crepitus
- Decreased grip strength
Correct answer: Joint crepitus
Crepitus is present when cartilage is lost. It is characterized by a popping or grating sound, or sometimes the patient feels bone rubbing against bone secondary to loss of cartilage. Decreased grip strength and bilateral joint swelling are more often seen in rheumatoid arthritis. A stooped posture is seen in osteoporosis.
- A client who recently quit smoking asks the nurse about the risks of developing lung cancer. Which of the following is the nurse's best response?
- For someone who quits smoking, the risk of developing lung cancer will remain constant and higher than for nonsmokers
- If lung cancer hasn't developed yet, the ongoing risk is the same as for a nonsmoker
- In 8 months, the risk of developing lung cancer will be twice as high as for a nonsmoker
- In 15 years, the risk of developing lung cancer will be the same as for a nonsmoker
Correct answer: In 15 years, the risk of developing lung cancer will be the same as for a nonsmoker
Over a long period, the damaged cells in the lungs can be replaced by healthy cells. In 15 years, this client's risk of developing lung cancer will be no higher than that of a nonsmoker. The benefits of quitting smoking begin within 20 minutes, when the heart rate returns to normal. After one month, cilia in the lungs start to recover. At one year, the risk of developing heart disease will be half that of a smoker.
- Which group of symptoms BEST indicates that a patient is experiencing pulmonary edema?
- Thick yellow sputum, hypotension, increased respirations
- Decreased respirations, tachycardia, bounding pulse
- Bradycardia, temporary confusion, decreased O2 saturation
- Sudden dyspnea, hypertension, orthopnea
Correct answer: Sudden dyspnea, hypertension, orthopnea
Pulmonary edema is the rapid accumulation of fluid in the tissues and air spaces of the lungs. The symptoms of pulmonary edema include sudden dyspnea, the need to sit up in order to breathe (orthopnea), cyanosis, pink frothy sputum, elevated pulse and blood pressure, and severe anxiety. The other answer options are incorrect groups of symptoms.
- While helping a new mother with breastfeeding, the nurse observes something unusual in the neonate. Then the nurse reviews the mother's history and notes "occasional use of alcohol" during pregnancy. Which observation would indicate that the alcohol use was more frequent?
- The neonate withdraws from touch
- The neonate has a poor gag reflex
- The neonate is difficult to arouse
- The neonate is shaking and irritable
Correct answer: The neonate is shaking and irritable
Fetal Alcohol Spectrum Disorder (FASD) is a range of conditions related to maternal alcohol use during pregnancy. Neonates display signs of withdrawal, including irritability, shaking, and high-pitched crying. As they grow, these children may have developmental disorders related to hyperactivity. The other answer options are not related to FASD.
- Before touching a crying client to offer comfort, the nurse should consider
- The client's cultural background
- Whether the client's family should be notified
- The client's recent vital signs and lab values
- Whether the client has been sad recently
Correct answer: The client's cultural background
Western culture uses therapeutic touch as a way to offer support or comfort, but other religions or cultures may consider it a violation of privacy. For example, Asians or Muslims do not welcome touch by strangers or by someone of the opposite gender. When in doubt, ask for permission or be conservative in your approach.
- You are taking the history of a 14-year-old girl who has a body mass index (BMI) of 18. The girl reports inability to eat, induced vomiting, and severe constipation. Which of the following would you most likely suspect?
- Bulimia nervosa
- Systemic sclerosis
- Anorexia nervosa
- Multiple sclerosis
Correct answer: Anorexia nervosa
All the clinical signs and symptoms point to anorexia nervosa. The key feature of anorexia nervosa is self-imposed starvation, resulting from a distorted body image and an intense, irrational fear of gaining weight, even when the patient is emaciated. Anorexia nervosa may include refusal to eat accompanied by compulsive exercising, self-induced vomiting, or laxative or diuretic abuse. On the other hand, bulimia nervosa is characterized by binge eating followed by feelings of guilt, humiliation, and self-deprecation. These feelings cause the patient to engage in self-induced vomiting and the use of laxatives or diuretics. Multiple sclerosis (MS) is a demyelinating disease in which the insulating covers of the nerve cells in the brain and spinal cord are damaged. Systemic sclerosis or systemic scleroderma is an autoimmune disease of the connective tissues.
- Two weeks after giving birth, a new mother calls the clinic and reports pronounced fatigue, sadness, and tearfulness. She states, "I feel so overwhelmed, I don't know what to do!" Which of the following questions is most appropriate for the nurse to ask?
- Is there a friend or a relative who can come and help you care for your baby?
- How much sleep do you get in a 24-hour period?
- Do you blame yourself for not being able to cope with motherhood?
- Do you ever think about harming yourself or your baby?
Correct answer: Do you ever think about harming yourself or your baby?
Feelings of fatigue, sadness, and tearfulness can be common symptoms experienced in the postpartum period. Postpartum blues usually occur in the first few days after giving birth. Postpartum depression usually begins 1-3 weeks after giving birth, but it can occur up to one year after giving birth. Both postpartum blues and postpartum depression share similar symptoms, such as sadness, crying spells, mood swings, irritability, and insomnia. However, clients who are diagnosed with postpartum depression may experience more severe symptoms, including thoughts of harming themselves or the infant.
- Which nursing action can help reduce a patient's postoperative pain and anxiety?
- Providing preoperative patient teaching
- Showing the patient the postoperative checklist
- Asking the social worker to assess the patient
- Ensuring that medication orders are provided
Correct answer: Providing preoperative patient teaching
Preoperative teaching not only teaches a patient what to expect after surgery but also reduces the patient's stress level and can decrease the amount of anesthesia required. A checklist is simply a form of documentation. Support from social services is normally not necessary. Medication orders are standard.
- A 42-year-old male with AIDS is admitted to the unit with Pneumocystis carinii pneumonia (PCP), an opportunistic infection. The patient tells the nurse that he feels hopeless. What is the most therapeutic action?
- Encourage the patient to set small daily goals
- Notify the client's next of kin of his mood
- Ask the client's clergy to visit the client
- Tell the client to consider a new hobby
Correct answer: Encourage the patient to set small daily goals
By setting small, achievable goals for each day, a person starts to gain hope and a sense of control. Hope is a powerful and sustaining emotion. If the patient requests a visit from family or clergy, these may also be helpful. A new hobby is not appropriate at this time.
- As you prep a patient for spinal surgery, he says, "I'm worried that this operation will only make my back pain worse." What is the nurse's most appropriate response?
- Everyone gets nervous before surgery. You'll be up and about soon
- I'm wondering if you still have questions about this procedure
- You've had back pain for too long. I'm sure this surgery will be helpful
- Your doctor is excellent. He knows exactly how to do this surgery
Correct answer: I'm wondering if you still have questions about this procedure
It is important for the nurse to allow patients to express their feelings. The nurse should also determine how much the patient knows and provide further teaching or clear up misconceptions. The other responses are not therapeutic.
- If a client is experiencing a panic attack, what mental health concept is most appropriate for the nurse to convey to the client?
- You're safe
- I believe you
- You're strong
- I trust you
Correct answer: You're safe
For a client who is having a panic attack, feeling safe is most important. Fear and loss of control can trigger a panic attack. The other answer options are components of a therapeutic relationship.
- When a healthcare provider is planning care for a patient diagnosed with Alzheimer's disease (AD), which of these interventions is most therapeutic?
- Giving the client several directions at a time to improve memory
- Encouraging both verbal and nonverbal communication
- Providing immediate feedback by correcting the client's speech
- Speaking in a loud, clear voice when talking to the client
Correct answer: Encouraging both verbal and nonverbal communication
As the ability to communicate verbally declines, nonverbal communication may become more prominent. Encouraging both can facilitate communication and decrease frustration. Speaking clearly and calmly is effective, but increasing the volume of the voice is not effective and can increase the client's anxiety. Giving several directions at a time is useless and frustrating for the client.
- When a 32-year-old mother is informed that she has Stage III breast cancer, what is likely to be her initial reaction?
Correct answer: Shock
The initial reaction to bad news is usually shock. Denial follows, when the client asks if the test results or diagnosis could be incorrect. Anger at the situation can develop, and the person may grieve over the loss of their health and future, but shock is the first response.
- Shortly after his 5-year-old daughter was hospitalized, a father tells the nurse he's concerned because his daughter has started to suck her thumb again. She had not sucked her thumb in over a year. What is the nurse's most appropriate response?
- I noticed this, too. I will contact the doctor right away
- Many children regress when they're in the hospital
- You must try to explain to your daughter that she's not a baby
- I was going to mention this to you. It's really not normal
Correct answer: Many children regress when they're in the hospital
Young children often deal with stress or anxiety with regressive behavior. Illness, pain, and separation from family cause distress. The child may return to a behavior that was soothing, such as thumbsucking or clinging to a favorite toy.
- The health care team refers a client who has been a victim of domestic violence to a local support group for domestic abuse victims. What is the reason for this referral?
- The client can develop meaningful new friendships
- The client will see that others have suffered more
- The support group teaches self-defense to its members
- Others with similar problems can offer emotional support
Correct answer: Others with similar problems can offer emotional support
Support, or self-help, groups let members provide support to each other. They allow members to speak openly about their situation and feelings without being judged by other members, who have had similar experiences. Friendships may develop, but that is not the purpose of the group. The other two answer options are incorrect.
- When a pregnant client complains of constipation, which intervention should the nurse offer?
- Take a gentle over-the-counter laxative
- Stop taking prenatal vitamins for a month
- Add more fruits and vegetables to the diet
- Increase yogurt and cheese consumption
Correct answer: Add more fruits and vegetables to the diet
Dietary fiber, water, and exercise are important for reducing constipation. Fruits and vegetables are rich sources of both nutrients and fiber. Some patients may experience constipation with dairy products, so increasing them is not recommended. Prenatal vitamins contain iron but should be continued throughout the pregnancy. Over-the-counter medications should be avoided during pregnancy.
- Which is the embryonic stage of pregnancy?
- Weeks 3-8
- Weeks 1–12
- Weeks 6–12
- Weeks 1-2
Correct answer: Weeks 3-8
The germinal stage happens in weeks 1–2 of pregnancy. The embryonic stage happens in weeks 3-8. The fetal stage lasts from week 9 until birth. Weeks 1-12 are the first trimester of pregnancy.
- When assessing gross motor skills, for which of the following infants should the nurse request a developmental referral?
- A 4-month-old who is unable to sit without support
- A 2-month-old who does not roll over
- A 6-month-old who does not creep
- A 9-month-old who is unable to stand while holding on
Correct answer: A 9-month-old who is unable to stand while holding on
Over 90% of infants who are 9 months old can stand if they have something to hold onto. Rolling over should occur between 4 and 6 months; sitting without support is expected at 6 months. Creeping is normal at about 9 months.
- From this client's medical history, which risk factor predisposes the client to developing varicose veins?
- Bowling league twice a week
- 30-pack-year history of smoking
- Job that involves sitting all day long
- Family history of varicose veins
Correct answer: Family history of varicose veins
Varicose veins are swollen, twisted, bulging veins that occur in the legs and ankles. Family history is the strongest predictor of developing the condition. Sitting or standing at a job may contribute to developing varicose veins, but this is not certain. Smoking and physical activity are not factors.
- An eight-year-old girl has been diagnosed with leukemia. According to Erickson, what is the developmental task for this age?
- Self-control and will power
- Self-confidence and competency
- Identity formation and sense of self
- Productivity and concern for others
Correct answer: Self-confidence and competency
Children ages 5-12 are working on becoming self-confident and gaining competency skills. (Industry vs. Inferiority) Self-control and will power are tasks for toddlers, ages 142–3 years. (Autonomy vs. Shame) Identity formation and sense of self occur in the teen years, ages 13-18. (Identity vs. Role Confusion) Productivity and concern for others happen at ages 40-65. (Generativity vs. Stagnation).
- A client with atrial fibrillation (Afib) is receiving instruction on using an electric razor for shaving. Which statement by the client shows the BEST understanding of the practice?
- An electric razor is easier to disinfect
- I need to avoid any cuts when I'm shaving
- Straight-edge razors can carry bacteria
- A cut could lead to serious infection
Correct answer: I need to avoid any cuts when I'm shaving
Clients with Afib are usually placed on an anticoagulant drug to prevent the formation of blood clots that could lead to a stroke. Because of this, the body's natural clotting mechanisms are slow to stop bleeding. Using an electric razor minimizes the risk of facial cuts. Not all cuts become infected, and not all straight-edge razors carry bacteria. Electric razors are cleaned, not disinfected.
- A neighbor brings her 10-year-old son to your house because he has a nosebleed. After you sit him down, what is the most appropriate way to care for him?
- Tilt his head back and place an ice pack on his nose
- Lean him forward and gently pinch above his nostrils
- Pack his nostrils with clean cotton balls or gauze
- Wipe off the blood and administer saline nose drops
Correct answer: Lean him forward and gently pinch above his nostrils
To stop a nosebleed, sit down and pinch the soft part of the nose, just above the nostrils. The bleeding should stop in 10-15 minutes. Leaning forward while doing this will allow the blood to exit by the nose, instead of down the throat. Tilting the head back can cause nausea. The other two answer options are incorrect.
- The nurse prepares to administer a pneumococcal vaccine to a 65-year-old client who has a diagnosis of chronic bronchitis. The client states, "I got that vaccine 5 years ago." What is the most appropriate response by the nurse?
- We can give you a flu shot instead of a pneumococcal vaccination
- You will need this vaccination annually, just like the flu shot
- This vaccination is given every other year to anyone with lung disease
- Your last shot was when you were 60, so a repeat vaccination is recommended
Correct answer: Your last shot was when you were 60, so a repeat vaccination is recommended
To help prevent pneumonia and its complications, a one-time repeat pneumococcal vaccination is recommended for individuals who were less than 65 years old when they received their first vaccination. Some high-risk groups receive an initial pneumonia vaccine of PCV13 (pneumococcal conjugate) before age 65. The CDC recommends a second vaccination of PCV23 (pneumococcal polysaccharide) at age 65 for these patients. Clients who are 65 and older should receive both vaccines, one year apart.
- After a 12-month-old receives her first measles-mumps-rubella (MMR) vaccination, the nurse gives the parents instructions on possible side effects of the injection. Which side effect is most important for the parents to report?
- Redness, swelling, and soreness at the injection site
- A fever that happens about 7 to 10 days after the vaccination
- A mild rash that appears 2 to 4 days following the vaccination
- Crying for more than two hours, even with consoling and comfort measures
Correct answer: Crying for more than two hours, even with consoling and comfort measures
Crying that can't be consoled is never normal. The parents should notify the office and investigate the reason for the child's distress. The other options are expected possible side effects of an MMR vaccination.
- A nurse gives a presentation at the library about preventing skin cancer, followed by a group discussion. Which comment by an attendee indicates the need for more teaching?
- I'll wear sunscreen when I go outside
- I’ll be sure to wear a hat and sunglasses
- I'll check my body each month for changes
- I'll get out between 10:00 a.m. and 2:00 p.m.
Correct answer: I'll get out between 10:00 a.m. and 2:00 p.m.
Sun exposure is most intense between the hours of 10:00 a.m. and 4:00 p.m. During this time, skin can be damaged, increasing the chance of developing skin cancer. The other answer options are correct statements.
- The nurse is instructing a teenager with type 1 diabetes (T1D) on testing his blood glucose level. He is very active in school sports. Besides routine blood glucose checks, the nurse also recommends that he do a check
- Every 4 hours throughout the school day
- After getting home from practice or a game
- Before participating in practice or a game
- When he feels his blood glucose level is low
Correct answer: Before participating in practice or a game
Checking the blood glucose level before exercise or activity is important to prevent hypoglycemia. Checking it after exercise or activity is prudent but should be done immediately. The other two answer options are incorrect.
- A client with type 1 diabetes comes to the clinic for a routine check-up. Which question should the nurse ask that addresses potential complications of diabetes?
- Do you take your blood pressure?
- What color is your urine?
- Have you had any breathing issues?
- When was your last vision exam?
Correct answer: When was your last vision exam?
Because diabetes affects blood flow to all organs, it can cause circulation to the eyes to be reduced, leading to poor vision. Diabetic retinopathy is a possible side effect, so clients with diabetes should have their vision checked at least once a year and notify their providers of any changes in vision. The other answer options are incorrect.
