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Based on your performance on this “NCLEX Cracker” Practice Test, you’re not yet ready for the NCLEX.
Keep your head up! Also, don’t focus on your estimated score, they mean essentially nothing at the start. Rarely does anyone start these exams and score well immediately, if that was the case then they wouldn’t even need to practice! These are ‘practice’ tests, meaning you’re practicing to improve your skills. If you continue to work hard and study, read and understand the solutions, practice with “NCLEX Cracker” daily and give it your best effort, we promise your score will improve. Review and learn for now, and the scores will come.
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Based on your performance on this “NCLEX Cracker” Practice Test, you barely missed the “passing” mark.
Keep your head up! Also, don’t focus on your estimated score, they mean essentially nothing at the start. Rarely does anyone start these exams and score well immediately, if that was the case then they wouldn’t even need to practice! These are ‘practice’ tests, meaning you’re practicing to improve your skills. If you continue to work hard and study, read and understand the solutions, practice with “NCLEX Cracker” daily and give it your best effort, we promise your score will improve. Review and learn for now, and the scores will come.
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Congratulations! Based on your performance on this “NCLEX Cracker” Practice Test, you’re predicted to pass your NCLEX! Keep hammering away at our NCLEX questions so that you can keep up the great work!
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A client diagnosed with dementia is having difficulty with care and cleaning of their hearing aid. What action by the nurse is most appropriate?
Rationale – It is very important to teach a family member how to use and care for a hearing aid especially in clients with cognitive impairment. Providing written instructions will not necessarily reinforce or help the client with the care. Having the client repeat the teaching provided is not the best option for care and cleaning. Instructing them to set an alarm will not necessarily help the client with care and cleaning.
Subcategory – Assistive Devices
Rationale – It is very important to teach a family member how to use and care for a hearing aid especially in clients with cognitive impairment. Providing written instructions will not necessarily reinforce or help the client with the care. Having the client repeat the teaching provided is not the best option for care and cleaning. Instructing them to set an alarm will not necessarily help the client with care and cleaning.
Subcategory – Assistive Devices
The client has recently began using a cane for ambulation. What action by the client indicates a need for further teaching?
Rationale – For full support the cane should be kept on the stronger side of the body. The weaker leg should be brought forward first. The cane should be advanced 10 inches in front of the body prior to moving legs. The cane should go from the base of the hip, the head of the greater trochanter, to the floor.
Subcategory – Assistive Devices
Rationale – For full support the cane should be kept on the stronger side of the body. The weaker leg should be brought forward first. The cane should be advanced 10 inches in front of the body prior to moving legs. The cane should go from the base of the hip, the head of the greater trochanter, to the floor.
Subcategory – Assistive Devices
A client is being evaluated for a possible diagnosis of constipation. What assessment findings are consistent with this diagnosis? Select all that apply.
Rationale – Constipation often results in bowel sounds decreased in all four quadrants. The client will often report limited water intake. The client often has pain in the left lower quadrant and it is also firm. Increase fiber intake would not support constipation, no fiber intake is commonly found in clients who do not have constipation. No bowel movement for four days is diagnostic for constipation, not two days.
Subcategory – Elimination
Rationale – Constipation often results in bowel sounds decreased in all four quadrants. The client will often report limited water intake. The client often has pain in the left lower quadrant and it is also firm. Increase fiber intake would not support constipation, no fiber intake is commonly found in clients who do not have constipation. No bowel movement for four days is diagnostic for constipation, not two days.
Subcategory – Elimination
A client is being discharged after having an ileostomy. What food choices indicate teaching regarding nutrition was effective? Select all that apply.
Rationale – Clients who have recently had an ass to me please I recommended to follow a low fiber diet for at least the first few weeks. No fiber diet would include eggs, bread and poultry. Vegetables and fresh fruits would be high fiber and not recommended in the first few weeks after an ileostomy.
Subcategory – Elimination
Rationale – Clients who have recently had an ass to me please I recommended to follow a low fiber diet for at least the first few weeks. No fiber diet would include eggs, bread and poultry. Vegetables and fresh fruits would be high fiber and not recommended in the first few weeks after an ileostomy.
Subcategory – Elimination
A client with an ileostomy has received teaching regarding prevention of blockages. What food selections by the client indicates a need for further teaching? Select all that apply.
Rationale – High fiber foods that can lead to blockages in the clients with ostomies include peas, black beans and nuts. Cream cheese and rice are both low fiber foods that are not found to cause blockages.
Subcategory – Elimination
Rationale – High fiber foods that can lead to blockages in the clients with ostomies include peas, black beans and nuts. Cream cheese and rice are both low fiber foods that are not found to cause blockages.
Subcategory – Elimination
A client is being seen in the emergency department after an injury to the wrist. The client is unable to move the palm towards the inner aspect of the forearm. What type of movement does the nurse document is altered?
Rationale – Flexion is the movement of the palm towards the inner aspect of the forearm. Extension would removing the hand in the opposite direction. Abduction would be extending the wrist towards the fifth finger. Adduction would be moving the wrist with palm down towards the thumb.
Subcategory – Mobility
Rationale – Flexion is the movement of the palm towards the inner aspect of the forearm. Extension would removing the hand in the opposite direction. Abduction would be extending the wrist towards the fifth finger. Adduction would be moving the wrist with palm down towards the thumb.
Subcategory – Mobility
A client is being assessed for the effects of immobility. What findings related to the cardiovascular system are consistent with immobility?
Rationale – Peripheral edema is consistent with the effects of immobility on the cardiovascular system. The client would likely experience orthostatic hypotension, tachycardia and would have a weak peripheral pulses.
Subcategory – Immobility
Rationale – Peripheral edema is consistent with the effects of immobility on the cardiovascular system. The client would likely experience orthostatic hypotension, tachycardia and would have a weak peripheral pulses.
Subcategory – Immobility
The nurse is teaching a pregnant client about the importance of folate in the diet. Which of the following foods should the nurse recommend the client add to her daily intake? Select all that apply.
Rationale – Spinach, avocado, and legumes are all good sources of folate. Folate is found in the egg yolk, not the whites. Apple juice is not a valid source of folate.
Subcategory – Nutrition and Oral Hydration
Rationale – Spinach, avocado, and legumes are all good sources of folate. Folate is found in the egg yolk, not the whites. Apple juice is not a valid source of folate.
Subcategory – Nutrition and Oral Hydration
A pregnant woman a 7 weeks of gestation presents to the prenatal clinic reporting nausea and vomiting upon waking, in the late afternoon, and at bedtime. Which of the following suggestions by the nurse may offer the client relief?
Rationale – By eating small, frequent meals the client is able to maintain blood sugar levels throughout the day. Other suggestions will only serve to worsen nausea.
Subcategory – Nutrition and Oral Hydration
Rationale – By eating small, frequent meals the client is able to maintain blood sugar levels throughout the day. Other suggestions will only serve to worsen nausea.
Subcategory – Nutrition and Oral Hydration
A client is prescribed a high calorie, high-protein diet. What food selections are appropriate for this nutritional therapy? Select all that apply.
Rationale – Casseroles, milkshakes and vegetables fried in butter are all high in calories and high in protein. Hot cereals with skim milk are not high in calories, grilled meats are not high in calories. Meats should be fried or served with Gravy or cream sauces.
Subcategory – Nutrition
Rationale – Casseroles, milkshakes and vegetables fried in butter are all high in calories and high in protein. Hot cereals with skim milk are not high in calories, grilled meats are not high in calories. Meats should be fried or served with Gravy or cream sauces.
Subcategory – Nutrition
A male client has several occurrences of urinary tract infections secondary to severe urinary retention. What type of catheterization does the nurse anticipate being ordered?
Rationale – A client with severe urinary retention who has had multiple episodes of urinary tract infections would likely benefit from long-term catheterization. Condom catheterization will not treat the retention. Intermittent catheterization increases the risk for infection. Short-term indwelling would result in retention afterwards as well as continued urinary tract infections.
Subcategory – Elimination
Rationale – A client with severe urinary retention who has had multiple episodes of urinary tract infections would likely benefit from long-term catheterization. Condom catheterization will not treat the retention. Intermittent catheterization increases the risk for infection. Short-term indwelling would result in retention afterwards as well as continued urinary tract infections.
Subcategory – Elimination
A client admitted to the emergency department is being prepared for surgery to repair a fractured femur. What order should be questioned by the nurse?
Rationale – Bilateral compression stockings would mean there would be a compression stocking on the affected side prior to surgery. This would be contraindicated with the femur fracture. Range of motion on the unaffected leg is indicated. The client should also be turned in repositioned every two hours. Heparin is often given prior to surgery and continued after surgery. All of these actions will help prevent thrombus formation.
Subcategory – Mobility/Immobility
Rationale – Bilateral compression stockings would mean there would be a compression stocking on the affected side prior to surgery. This would be contraindicated with the femur fracture. Range of motion on the unaffected leg is indicated. The client should also be turned in repositioned every two hours. Heparin is often given prior to surgery and continued after surgery. All of these actions will help prevent thrombus formation.
Subcategory – Mobility/Immobility
A client with the peripherally inserted venous access device experienced an infiltration. What interventions are appropriate to decrease discomfort in this area?
Rationale – Elevating the arm will help with inflammation and pain in the area. Heat, not ice should be applied. Massaging the area will not decrease discomfort. A topical pain medication cannot be applied to an open area such as an IV insertion site.
Subcategory – Non-pharmacological Comfort Interventions
Rationale – Elevating the arm will help with inflammation and pain in the area. Heat, not ice should be applied. Massaging the area will not decrease discomfort. A topical pain medication cannot be applied to an open area such as an IV insertion site.
Subcategory – Non-pharmacological Comfort Interventions
A client is groggy but aware of their surroundings. What stage of sleep is the client most likely in?
Rationale – In NREM stage I the client is often groggy and where their surroundings. REM is highly active sleep with spontaneous awakening. Stage two and three the client would be sleeping.
Subcategory – Sleep
Rationale – In NREM stage I the client is often groggy and where their surroundings. REM is highly active sleep with spontaneous awakening. Stage two and three the client would be sleeping.
Subcategory – Sleep
The nurse is assessing a client for sleep deprivation. What signs and symptoms are consistent with this diagnosis? Select all that apply.
Rationale – A client with sleep deprivation would have impaired cognitive functioning and malaise. Hypertension and low body temperature are not signs of sleep deprivation. They would have a decrease not increase reaction time.
Subcategory – Sleep
Rationale – A client with sleep deprivation would have impaired cognitive functioning and malaise. Hypertension and low body temperature are not signs of sleep deprivation. They would have a decrease not increase reaction time.
Subcategory – Sleep
A male client has asked to have their face shaved. What action by the unlicensed assistive personnel indicates a need for further teaching?
Rationale – It is important to shave it in the same direction as the hair growth, not in the opposite direction. Long strokes to be used over large areas. Shorter strokes around shorter areas such as the chin and lips. An electric razor should be used if the client is at risk
Subcategory – Hygiene
Rationale – It is important to shave it in the same direction as the hair growth, not in the opposite direction. Long strokes to be used over large areas. Shorter strokes around shorter areas such as the chin and lips. An electric razor should be used if the client is at risk
Subcategory – Hygiene
What nursing intervention is priority in a client who is edentulous?
Rationale – Inspecting the gums and oral cavity is important in a client with edentulous (someone without teeth). A soft diet is important but not priority. Requesting a nutritional consult may be indicated but is not priority. Oral care does not need to be performed every two hours.
Subcategory – Hygiene
Rationale – Inspecting the gums and oral cavity is important in a client with edentulous (someone without teeth). A soft diet is important but not priority. Requesting a nutritional consult may be indicated but is not priority. Oral care does not need to be performed every two hours.
Subcategory – Hygiene
Which position is recommended for prevention of esophageal reflux and involves the foot of the bed being down with the entire bed frame tilted?
Rationale – Reverse Trendelenburg position promotes esophageal reflux and gastric emptying. It involves the entire bed frame being tilted with the foot of the bed down.
Subcategory – Non-pharmacological comfort measures
Rationale – Reverse Trendelenburg position promotes esophageal reflux and gastric emptying. It involves the entire bed frame being tilted with the foot of the bed down.
Subcategory – Non-pharmacological comfort measures
A client diagnosed with Alzheimer’s disease is having episodes of restlessness and is wandering around the unit yelling and screaming. What intervention by the nurse is most appropriate?
Rationale – When a client is restless wandering and yelling it is important to have someone stay with the client to maintain safety. Risperidone and other antipsychotics cannot be administered if ordered to control behavioral issues in clients with Alzheimer’s or dementia. Moving the client’s room closer to the nurse’s desk is a good idea but not priority at this time. Administering a chest restraint should not be done unless the client is at risk of harming themselves or others and would require an order.
Subcategory – Aging Process
Rationale – When a client is restless wandering and yelling it is important to have someone stay with the client to maintain safety. Risperidone and other antipsychotics cannot be administered if ordered to control behavioral issues in clients with Alzheimer’s or dementia. Moving the client’s room closer to the nurse’s desk is a good idea but not priority at this time. Administering a chest restraint should not be done unless the client is at risk of harming themselves or others and would require an order.
Subcategory – Aging Process
The nurse identifies which intrinsic factors that may lead to false hospitalized in an older adult client? Select all that apply.
Rationale – Intrinsic factors would include physiologic changes in medications. Extrinsic factors would be the cluttered rooms and wheels on chairs in being unfamiliar with an environment.
Subcategory – Aging Process
Rationale – Intrinsic factors would include physiologic changes in medications. Extrinsic factors would be the cluttered rooms and wheels on chairs in being unfamiliar with an environment.
Subcategory – Aging Process
During a routine prenatal visit, a woman at 33 weeks gestation lies supine while nurse auscultates the fetal heart tones. During the nurse’s exam, the woman becomes flushed, diaphoretic and complains of dizziness. Which of the following is the priority nursing intervention?
Rationale – Turning the woman on her side to relieve compression of the vena cava and restore normal perfusion to the upper body. Calling for help is not indicated at this time. Obtaining full vital signs, and continuing auscultating the fetal heart tones are not priority.
Subcategory – Ante/Intra/Postpartum and Newborn Care
Rationale – Turning the woman on her side to relieve compression of the vena cava and restore normal perfusion to the upper body. Calling for help is not indicated at this time. Obtaining full vital signs, and continuing auscultating the fetal heart tones are not priority.
Subcategory – Ante/Intra/Postpartum and Newborn Care
A pregnant client asks the nurse about the benefits of performing Kegel exercises during pregnancy. The nurse knows Kegel exercises are important for which of the following reasons? Select all that apply.
Rationale – Strengthening the pelvic floor will lead to the factors outlined in these choices. Kegel exercises are not associated with preterm labor or duration of labor.
Subcategory – Ante/Intra/Postpartum and Newborn Care
Rationale – Strengthening the pelvic floor will lead to the factors outlined in these choices. Kegel exercises are not associated with preterm labor or duration of labor.
Subcategory – Ante/Intra/Postpartum and Newborn Care
A client at 15 weeks gestation reports constipation, and asks the nurse how to restore bowel regularity. Which of the following is the most appropriate nursing response?
Rationale – Therapeutic communication opens discussion and will help client understand importance of increased fluid intake and physical activity during pregnancy can help alleviate constipation.
Subcategory – Ante/Intra/Postpartum and Newborn Care
Rationale – Therapeutic communication opens discussion and will help client understand importance of increased fluid intake and physical activity during pregnancy can help alleviate constipation.
Subcategory – Ante/Intra/Postpartum and Newborn Care
The postpartum nurse is assisting a new mother with breastfeeding. The infant has not fed in 5 hours, is crying, and will not latch. Which of the following interventions by the nurse is most appropriate?
Rationale – A fussy baby is unable to organize themselves enough to latch properly. Placing the baby skin-to-skin will help calm mom and baby so BF can be re-attempted. A pacifier and formula will only serve to interrupt BF efforts.
Subcategory – Ante/Intra/Postpartum and Newborn Care
Rationale – A fussy baby is unable to organize themselves enough to latch properly. Placing the baby skin-to-skin will help calm mom and baby so BF can be re-attempted. A pacifier and formula will only serve to interrupt BF efforts.
Subcategory – Ante/Intra/Postpartum and Newborn Care
A young adult client is admitted to the hospital after a motor vehicle accident resulting in multiple fractures. What action by the nurse supports the client’s psychosocial stage according to Erickson?
Rationale – Young adult’s psychosocial development at this level is intimacy versus isolation. The nurse promoting the significant other to spend time with the client will help establish intimacy. Promoting reflection on successes in their life is integrity versus despair.
Providing opportunities to do their own care does not assist them at this developmental level. Encouraging them to use an assistive device would not be used to promote their psychosocial development.
Subcategory – Developmental Stages
Rationale – Young adult’s psychosocial development at this level is intimacy versus isolation. The nurse promoting the significant other to spend time with the client will help establish intimacy. Promoting reflection on successes in their life is integrity versus despair.
Providing opportunities to do their own care does not assist them at this developmental level. Encouraging them to use an assistive device would not be used to promote their psychosocial development.
Subcategory – Developmental Stages
A five-year-old child is admitted to the hospital with a new diagnosis of leukemia. What actions by the nurse best supports their cognitive development according to Piaget?
Rationale – Children during the preoperational years develop cognitively through play and imagination. Assisting them to read a book is something the nurse can do but is not the best option to promote growth and the preoperational face. Teaching the client about the illness is not going to help cognitive development. A child should understand object permanence by the time they reach the preoperational face.
Subcategory – Developmental Stages
Rationale – Children during the preoperational years develop cognitively through play and imagination. Assisting them to read a book is something the nurse can do but is not the best option to promote growth and the preoperational face. Teaching the client about the illness is not going to help cognitive development. A child should understand object permanence by the time they reach the preoperational face.
Subcategory – Developmental Stages
The parents of an 18-month-old toddler have received education regarding nutritional needs of their child. What selections by the parents indicate a need for further teaching?
Rationale – Toddlers should be encouraged to eat finger foods. Foods requiring utensils will not promote their independence. Small reasonable serving should be provided to allow them to eat all of their meals. Because of their need for fat toddlers should be offered whole milk until the age of two. Low-fat or skim milk should not be introduced until after that point. Nutritional snacks should be provided in between meals especially in children who prefer one type of food.
Subcategory – Health Promotion
Rationale – Toddlers should be encouraged to eat finger foods. Foods requiring utensils will not promote their independence. Small reasonable serving should be provided to allow them to eat all of their meals. Because of their need for fat toddlers should be offered whole milk until the age of two. Low-fat or skim milk should not be introduced until after that point. Nutritional snacks should be provided in between meals especially in children who prefer one type of food.
Subcategory – Health Promotion
A seven-year-old child is admitted to the hospital for surgery. And order has been placed for urinary catheter. What action by the nurse is most appropriate at this age?
Rationale – A seven-year-old child will need privacy and should have the procedure explain to them prior to entering the room to perform the catheterization. Demonstrating the procedure on a stuffed animal would be done for younger children. Showing the child the video of the urinary catheterization is not appropriate at this age level. Having the parents explain the procedure is not appropriate.
Subcategory – Health Promotion
Rationale – A seven-year-old child will need privacy and should have the procedure explain to them prior to entering the room to perform the catheterization. Demonstrating the procedure on a stuffed animal would be done for younger children. Showing the child the video of the urinary catheterization is not appropriate at this age level. Having the parents explain the procedure is not appropriate.
Subcategory – Health Promotion
What action by the nurse contribute to a client’s sense of well-being? Select all that apply.
Rationale – Part of contributing to the client sense of well-being is establishing the presents, listening to their concerns and paying attention to them. Changing a client stressing is an action of doing which is not considered being with the client. Encouraging them to call the physician with questions is not considered being with the client.
Subcategory – Health Promotion
Rationale – Part of contributing to the client sense of well-being is establishing the presents, listening to their concerns and paying attention to them. Changing a client stressing is an action of doing which is not considered being with the client. Encouraging them to call the physician with questions is not considered being with the client.
Subcategory – Health Promotion
A client who has been diagnosed with urinary sphincter dysfunction has received teaching on use of Kegel exercises. Which action by the client demonstrates a need for further teaching?
Rationale – The client should be instructed to avoid tensing the muscles of the legs buttocks or abdomen when sitting or standing. They should use Kegel exercises 30-100 times a day. The client should contract the sphincter muscles for 10 seconds then relax them for 10 seconds. They should be instructed to do Kegel exercises before sneezing or coughing.
Subcategory – Disease Prevention
Rationale – The client should be instructed to avoid tensing the muscles of the legs buttocks or abdomen when sitting or standing. They should use Kegel exercises 30-100 times a day. The client should contract the sphincter muscles for 10 seconds then relax them for 10 seconds. They should be instructed to do Kegel exercises before sneezing or coughing.
Subcategory – Disease Prevention
What interventions are appropriate to promote bladder emptying for a client diagnosed with urge incontinence? Select all that apply.
Rationale – Administering tolterodine, Pelvic floor exercises and bladder retraining are all interventions used to promote bladder emptying and clients diagnosed with urgent incontinence. Intermittent catheterization is recommended for clients with overflow incontinence. Limiting carbonated beverages is recommended for clients with hyperactive are overactive bladder.
Subcategory – Disease Prevention
Rationale – Administering tolterodine, Pelvic floor exercises and bladder retraining are all interventions used to promote bladder emptying and clients diagnosed with urgent incontinence. Intermittent catheterization is recommended for clients with overflow incontinence. Limiting carbonated beverages is recommended for clients with hyperactive are overactive bladder.
Subcategory – Disease Prevention
A client has an order for an enema. What type of enema would be used to create an intestinal irritation that will stimulate peristalsis?
Rationale – Soapsuds enema is used to create intestinal irritation to stimulate peristalsis. A tap water enema exert an osmotic pressure to promote defecation. An oil retention enema lubricates the rectum and colon. A sodium polystyrene sulfonate enema is used to treat clients with high sodium levels. This drug contains a resin that will exchange sodium for potassium ions in the intestine.
Subcategory – Health Promotion
Rationale – Soapsuds enema is used to create intestinal irritation to stimulate peristalsis. A tap water enema exert an osmotic pressure to promote defecation. An oil retention enema lubricates the rectum and colon. A sodium polystyrene sulfonate enema is used to treat clients with high sodium levels. This drug contains a resin that will exchange sodium for potassium ions in the intestine.
Subcategory – Health Promotion
What intervention is an example of health promotion related to mobility? Select all that apply.
Rationale – Health promotion related to mobility includes screening school-age children for scoliosis, encouraging early ambulation and postoperative clients and including ergonomic training to employees. Pleasing a splint and a muscle strain it would be an intervention post injury. Requiring employees to be released by facility healthcare provider before returning to work is not health promotion.
Subcategory – Health Promotion
Rationale – Health promotion related to mobility includes screening school-age children for scoliosis, encouraging early ambulation and postoperative clients and including ergonomic training to employees. Pleasing a splint and a muscle strain it would be an intervention post injury. Requiring employees to be released by facility healthcare provider before returning to work is not health promotion.
Subcategory – Health Promotion
A client is admitted to the hospital with a diagnosis of dehydration. What other factors should the nurse assessed the client for when determining their risk for pressure ulcer development? Select all that apply.
Rationale – Factors leading to formation of a pressure ulcer would include decreases in sensory perception moisture and friction and shearing forces. Understanding of pressure ulcer formation and normal skin care are not factors that lead to formation of pressure ulcers and hospitalized clients.
Subcategory – Health Promotion
Rationale – Factors leading to formation of a pressure ulcer would include decreases in sensory perception moisture and friction and shearing forces. Understanding of pressure ulcer formation and normal skin care are not factors that lead to formation of pressure ulcers and hospitalized clients.
Subcategory – Health Promotion
After receiving teaching regarding correct use of condoms, what statement by a client indicates a need for further teaching?
Rationale – Water-based lubricant may help with prevention of condom breaking, petroleum jelly should not be used. They should store condoms in a cool dry place. The client should hold a condom when pulling out. They should also be instructed to check expiration dates on condoms.
Subcategory – High Risk Behaviors
Rationale – Water-based lubricant may help with prevention of condom breaking, petroleum jelly should not be used. They should store condoms in a cool dry place. The client should hold a condom when pulling out. They should also be instructed to check expiration dates on condoms.
Subcategory – High Risk Behaviors
The nurses assessing the pulse oximetry of a client admitted for smoke inhalation. The client’s pulse oximetry is reading at 70% on room air although the client is pink and is not an apparent distress. The client’s radial pulse differs from the pulse on the client’s pulse rate indicated by the oximeter. What action by the nurse is most appropriate?
Rationale – If the oximeter pulse and the radial pulse differ the nurse should reposition the oximeter to get a proper reading. Assessing the apical pulse will not change the difference between the two. High-flow oxygen is not indicated unless the oximetry reading is low when consistent with the pulse. Repositioning the client will not give a proper oximetry reading.
Subcategory – Physical Assessment
Rationale – If the oximeter pulse and the radial pulse differ the nurse should reposition the oximeter to get a proper reading. Assessing the apical pulse will not change the difference between the two. High-flow oxygen is not indicated unless the oximetry reading is low when consistent with the pulse. Repositioning the client will not give a proper oximetry reading.
Subcategory – Physical Assessment
A client is admitted to the hospital with a cardiac arrhythmia. Upon assessment the nurse assesses turgor and determines the late and recoil. What is the most important for the nurse to assess?
Rationale – A client with poor skin turgor is likely to be dehydrated. Fat distribution is not related to this finding. Edema would be a sign of fluid overload. A full skin assessment is not priority.
Subcategory – Techniques for Physical Assessment
Rationale – A client with poor skin turgor is likely to be dehydrated. Fat distribution is not related to this finding. Edema would be a sign of fluid overload. A full skin assessment is not priority.
Subcategory – Techniques for Physical Assessment
Which intervention is most appropriate to assigned to an unlicensed assistive personnel?
Rationale – An unlicensed assistive personnel is able to take an electrocardiogram reading but not interpret it. They should not place a client in traction. They cannot administer a suppository, they do not process.
Subcategory- Assignment, Delegation and Supervision
Rationale – An unlicensed assistive personnel is able to take an electrocardiogram reading but not interpret it. They should not place a client in traction. They cannot administer a suppository, they do not process.
Subcategory- Assignment, Delegation and Supervision
The new graduate nurse meets with her preceptor about an orientation plan. The graduate is asking what they would like to focus on and comfort levels in care. What type of leadership style does the preceptor exhibit?
Rationale – The preceptor allows the nurse input and insight into their skills and needs. This demonstrates democratic leadership skills. An Autocratic leader would tell them what they needed to do. Bureaucratic is not represented by this example. A laissez-faire would not ask the input of the nurse.
Subcategory- Concepts of Management
Rationale – The preceptor allows the nurse input and insight into their skills and needs. This demonstrates democratic leadership skills. An Autocratic leader would tell them what they needed to do. Bureaucratic is not represented by this example. A laissez-faire would not ask the input of the nurse.
Subcategory- Concepts of Management
Which client is most appropriate to assigned to a licensed vocational nurse?
Rationale – The LVN is able to administer breathing treatments to a client with pneumonia going to short of breath. They are not able to administer the IV push medication and they are cannot give Cardizem IV. The LVN cannot administer platelets.
Subcategory- Assignment, Delegation and Supervision
Rationale – The LVN is able to administer breathing treatments to a client with pneumonia going to short of breath. They are not able to administer the IV push medication and they are cannot give Cardizem IV. The LVN cannot administer platelets.
Subcategory- Assignment, Delegation and Supervision
The nurse is assigned the following for clients. Which client should the nurse see first?
Rationale – The client needs to be assessed frequently for the first couple hours post cardiac catheterization. The insertion site also needs to be assessed for swelling or bleeding. The client with heart failure would likely be seen next. The client with atrial fibrillation is the least serious of the four and can be seen last. The client with the attack in a potassium of 8.5 has had dialysis to treat the potassium.
Subcategory – Establishing Priorities
Rationale – The client needs to be assessed frequently for the first couple hours post cardiac catheterization. The insertion site also needs to be assessed for swelling or bleeding. The client with heart failure would likely be seen next. The client with atrial fibrillation is the least serious of the four and can be seen last. The client with the attack in a potassium of 8.5 has had dialysis to treat the potassium.
Subcategory – Establishing Priorities
The nurse is assigned the following four clients. Which client should the nurse see first?
Rationale – An INR of 4.7 is extremely elevated and places the client at risk for bleeding. A client with tuberculosis would be expected to have a positive sputum culture. The client with pneumonia would be expected to have an elevated white blood cell count. The client was COPD would be expected to have a low pH with her elevated CO2.
Subcategory – Establishing Priorities
Rationale – An INR of 4.7 is extremely elevated and places the client at risk for bleeding. A client with tuberculosis would be expected to have a positive sputum culture. The client with pneumonia would be expected to have an elevated white blood cell count. The client was COPD would be expected to have a low pH with her elevated CO2.
Subcategory – Establishing Priorities
A charge nurse is making the assignment for the night. Which client should be placed with the most experienced nurse?
Rationale – An elevated potassium places the client at risk for cardiac complications and should be addressed immediately. The client with nephrolithiasis would likely have flank pain and should be seen but is not priority. The client with urinary retention in need of a catheter should be seen but is not priority over a client with a potassium of 6.0. The client with chronic renal failure would be expected to have an elevated BUN.
Subcategory – Assignment, Delegation and Supervision
Rationale – An elevated potassium places the client at risk for cardiac complications and should be addressed immediately. The client with nephrolithiasis would likely have flank pain and should be seen but is not priority. The client with urinary retention in need of a catheter should be seen but is not priority over a client with a potassium of 6.0. The client with chronic renal failure would be expected to have an elevated BUN.
Subcategory – Assignment, Delegation and Supervision
The charge nurse is making assignments for the shift. Which client should be assigned to the most experienced nurse?
Rationale – The client with hypoglycemia needs an acute intervention and should be seen by the most experienced nurse. The client with DKA has come off of the insulin drip and is now on a sliding scale. The client with type two diabetes will require teaching but can be assigned to any nurse. The client with age HNS is receiving treatment.
Subcategory – Assignment, Delegation and Supervision
Rationale – The client with hypoglycemia needs an acute intervention and should be seen by the most experienced nurse. The client with DKA has come off of the insulin drip and is now on a sliding scale. The client with type two diabetes will require teaching but can be assigned to any nurse. The client with age HNS is receiving treatment.
Subcategory – Assignment, Delegation and Supervision
A client is brought to the emergency room and is experiencing an acute myocardial infarction which order should the nurse implement first?
Rationale – The interventions that should be performed first are morphine and oxygen nitroglycerin and aspirin and a client who is experiencing a myocardial infarction. Morphine should be administered first, Lopressor next then and repeat EKG. An echocardiogram would be the last priority.
Subcategory – Establishing Priorities
Rationale – The interventions that should be performed first are morphine and oxygen nitroglycerin and aspirin and a client who is experiencing a myocardial infarction. Morphine should be administered first, Lopressor next then and repeat EKG. An echocardiogram would be the last priority.
Subcategory – Establishing Priorities
What intervention is priority for a client with a suspected urinary tract infection who has a white blood cell count of 13,000 and a temperature of 101.1°F?
Rationale – A urine culture should be obtained before antibiotics are administered. Sitz baths are not a priority and may be contraindicated. Acetaminophen can be given after the urine culture and antibiotic administration.
Subcategory – Establishing Priorities
Rationale – A urine culture should be obtained before antibiotics are administered. Sitz baths are not a priority and may be contraindicated. Acetaminophen can be given after the urine culture and antibiotic administration.
Subcategory – Establishing Priorities
What assessment is priority for a client diagnosed with a deep vein thrombosis?
Rationale – A major complication of a deep in thrombosis is pulmonary embolism and therefore the respiratory assessment should be done. Integumentary a musculoskeletal are not priority assessment. Peripheral vascular assessment will likely be altered as the client already has a deep vein thrombosis.
Subcategory – Establishing Priorities
Rationale – A major complication of a deep in thrombosis is pulmonary embolism and therefore the respiratory assessment should be done. Integumentary a musculoskeletal are not priority assessment. Peripheral vascular assessment will likely be altered as the client already has a deep vein thrombosis.
Subcategory – Establishing Priorities
The nurse has the following four clients. Which client can be delegated to a licensed vocational nurse?
Rationale – The client with a test tube draining my gravity is the least invasive procedure that will require the least amount of assessment.
Subcategory – Assignment, Delegation and Supervision
Rationale – The client with a test tube draining my gravity is the least invasive procedure that will require the least amount of assessment.
Subcategory – Assignment, Delegation and Supervision
The family member of the client admitted for Crohn’s disease reports to the charge nurse that the nurses have not been medicated the client for pain. What action by the charge nurse is priority?
Rationale – The first intervention the charge nurse to do is check the medication administration record to see if the medications have been administered. After checking the MAR the nurse may want to talk to the nurses involved. Talking to the client may be indicated but is not priority. A written complaint is not priority.
Subcategory – Assignment, Delegation and Supervision
Rationale – The first intervention the charge nurse to do is check the medication administration record to see if the medications have been administered. After checking the MAR the nurse may want to talk to the nurses involved. Talking to the client may be indicated but is not priority. A written complaint is not priority.
Subcategory – Assignment, Delegation and Supervision
A client diagnosed with heart failure has a weight gain of 2.5 pounds, pitting edema and crackles in the bases bilaterally. What order should be implemented first?
Rationale – Medication should be administered to reduce the fluid overload. Fluid restriction and daily weights are important but not priority. Urinary catheter insertion is not indicated and less ordered by the healthcare provider for strict I & O’s.
Subcategory – Establishing Priorities
Rationale – Medication should be administered to reduce the fluid overload. Fluid restriction and daily weights are important but not priority. Urinary catheter insertion is not indicated and less ordered by the healthcare provider for strict I & O’s.
Subcategory – Establishing Priorities
What intervention is priority for a client suspected of having tuberculosis?
Rationale – The priority intervention for a client suspected of having tuberculosis is airborne isolation. A chest x-ray in full respiratory assessment are important, however placing the client an airborne isolation should be priority. A PPD placement will only detect exposure to tuberculosis, a sputum culture would be needed for diagnosis.
Subcategory – Establishing Priorities
Rationale – The priority intervention for a client suspected of having tuberculosis is airborne isolation. A chest x-ray in full respiratory assessment are important, however placing the client an airborne isolation should be priority. A PPD placement will only detect exposure to tuberculosis, a sputum culture would be needed for diagnosis.
Subcategory – Establishing Priorities
What finding requires immediate intervention if found in a client having an exercise stress test?
Rationale – Chest pain should not occur and would require the nurse to stop the stress test. Dyspnea is not an abnormal finding. Blood pressure may be elevated as would pulse.
Subcategory – Establishing Priorities
Rationale – Chest pain should not occur and would require the nurse to stop the stress test. Dyspnea is not an abnormal finding. Blood pressure may be elevated as would pulse.
Subcategory – Establishing Priorities
A client is brought to the emergency department with an ST segment elevation and chest pain. What orders can be implemented by an unlicensed assistive personnel? Select all that apply.
Rationale – An unlicensed assistive personnel may attach a cardiac monitor, obtain a 12 lead EKG. They may also gather the client’s vital signs. Assessing pain should also be done by a nurse. Nitroglycerin would need to be administered by a nurse.
Subcategory – Assignment, Delegation and Supervision
Rationale – An unlicensed assistive personnel may attach a cardiac monitor, obtain a 12 lead EKG. They may also gather the client’s vital signs. Assessing pain should also be done by a nurse. Nitroglycerin would need to be administered by a nurse.
Subcategory – Assignment, Delegation and Supervision
A client experiencing a myocardial infarction is being seen in the emergency room. What interventions can be performed by a licensed vocational nurse? Select all that apply.
Rationale – An LVN may administer sublingual nitroglycerin and have a client chew the baby aspirin. IV morphine is given push and cannot be done by LVN. Heparin drip needs to be titrated and cannot be hung by LVN. Chest pain evaluation is a form of assessment and needs to be done by a registered nurse.
Subcategory – Assignment, Delegation and Supervision
Rationale – An LVN may administer sublingual nitroglycerin and have a client chew the baby aspirin. IV morphine is given push and cannot be done by LVN. Heparin drip needs to be titrated and cannot be hung by LVN. Chest pain evaluation is a form of assessment and needs to be done by a registered nurse.
Subcategory – Assignment, Delegation and Supervision
The client smokes two packs of cigarettes per day and reports a recent loss of their husband. What discharge teaching is priority to include for a client with a new diagnosis of COPD? Select all that apply.
Rationale – It is important to address immediate concerns and issues that are arising in the client’s situation. Referral for smoking cessation, information on support groups and proper use of inhalers are priority for a client with a new diagnosis of COPD who smokes two packs of cigarettes a day and reports the recent loss of their husband. Stress reduction exercises are not a priority. Risk factors for cardiovascular disease do not need to be included at this time, maybe discussed at a leader follow-up appointment.
Subcategory – Case Management
Rationale – It is important to address immediate concerns and issues that are arising in the client’s situation. Referral for smoking cessation, information on support groups and proper use of inhalers are priority for a client with a new diagnosis of COPD who smokes two packs of cigarettes a day and reports the recent loss of their husband. Stress reduction exercises are not a priority. Risk factors for cardiovascular disease do not need to be included at this time, maybe discussed at a leader follow-up appointment.
Subcategory – Case Management
What actions by the nurse are necessary when witnessing an informed consent? Select all that apply.
Rationale – It is important that the nurse has checked to make sure the client has not received medications they can alter judgment. It is also important that they determine the client is fully aware of the teaching that has been provided. Including alternatives to the procedure. Clients can sign and informed consent if they are over 18. A durable power of attorney does not influence and informed consent if the client is alert and oriented.
Subcategory – Informed Consent
Rationale – It is important that the nurse has checked to make sure the client has not received medications they can alter judgment. It is also important that they determine the client is fully aware of the teaching that has been provided. Including alternatives to the procedure. Clients can sign and informed consent if they are over 18. A durable power of attorney does not influence and informed consent if the client is alert and oriented.
Subcategory – Informed Consent
What member of the healthcare team is responsible for obtaining an informed consent?
Rationale – The healthcare provider is responsible for obtaining informed consent. The RN case manager or charge nurse me witness but are not responsible for obtaining the informed consent.
Subcategory – Informed Consent
Rationale – The healthcare provider is responsible for obtaining informed consent. The RN case manager or charge nurse me witness but are not responsible for obtaining the informed consent.
Subcategory – Informed Consent
Which organization is responsible for governing the nursing code of ethics?
Rationale – The American Nurses Association is responsible for governing the nursing code of ethics. The NLN, NIH and AACN are not responsible for governing the nurse code of ethics.
Subcategory – Ethical Practice
Rationale – The American Nurses Association is responsible for governing the nursing code of ethics. The NLN, NIH and AACN are not responsible for governing the nurse code of ethics.
Subcategory – Ethical Practice
The nurse accessed the record of a client that she is not assigned for. Upon further investigation it was determined that the nurse had accessed the chart to find information for a friend. What health care legislation is most applicable in this situation?
Rationale – Accessing a client’s chart is a violation of the healthcare insurance portability and accountability act. While the nurses acting unethically, the most applicable would be HIPAA.
Subcategory – Information Technology
Rationale – Accessing a client’s chart is a violation of the healthcare insurance portability and accountability act. While the nurses acting unethically, the most applicable would be HIPAA.
Subcategory – Information Technology
The client is reporting 8/10 abdominal pain after an abdominal hysterectomy. The nurse has placed several calls to the surgeon with no return call. The nurse approaches the charge nurse and finally is able to get an order for pain medication. What ethical principle does this demonstrate?
Rationale – Fidelity refers to integrity it is achieved by advocacy and dedication.
Subcategory – Ethical Practice
Rationale – Fidelity refers to integrity it is achieved by advocacy and dedication.
Subcategory – Ethical Practice
A client with urinary retention refuses a urinary catheter. The nurse administers PRN Ativan and insert the catheter. What is the nurse liable for?
Rationale – Battery is willful touching of a person without permission. Assault is the act of creating apprehension of an imminent harmful or offensive contact with a person.
Subcategory – Ethical Practice
Rationale – Battery is willful touching of a person without permission. Assault is the act of creating apprehension of an imminent harmful or offensive contact with a person.
Subcategory – Ethical Practice
A client with pulmonary hypertension has received teaching about epoprosterol treatment. The medication will prolong the client’s life. Without the medication the client is expected to live no more than one year. The client has opted to not receive the medication and would like end-of-life information. What ethical principle does this demonstrate?
Rationale – Autonomy refers to the client’s right to make their own decision.
Subcategory – Ethical Practice
Rationale – Autonomy refers to the client’s right to make their own decision.
Subcategory – Ethical Practice
The nurse witnesses an unlicensed assistive personnel being rough when handling a client. The nurse reporting the incident is an example of what ethical principle?
Rationale – Beneficence is the act of doing what is best for the client. Reporting the incident is acting in the client’s best interest.
Subcategory – Ethical Practice
Rationale – Beneficence is the act of doing what is best for the client. Reporting the incident is acting in the client’s best interest.
Subcategory – Ethical Practice
The nurse is caring for a client diagnosed with a left sided cerebrovascular accident. The client is experiencing hemiparesis. What action by the nurse is appropriate?
Rationale – A client with a left sided cerebrovascular accident will have deficits on the right side. Placing objects on the left side will allow them to reach and utilize them. Approaching the client from the right is not appropriate as their hemiparesis will be on that side. Passive range of motion will not be necessary on the side as it will not be the affected side. Encouraging them to answer questions by blinking are nodding is not indicated.
Subcategory – Establishing Priorities
Rationale – A client with a left sided cerebrovascular accident will have deficits on the right side. Placing objects on the left side will allow them to reach and utilize them. Approaching the client from the right is not appropriate as their hemiparesis will be on that side. Passive range of motion will not be necessary on the side as it will not be the affected side. Encouraging them to answer questions by blinking are nodding is not indicated.
Subcategory – Establishing Priorities
What action by the nurse caring for a client with chronic obstructive pulmonary disease requires intervention by a nurse supervisor?
Rationale – A client with COPD should not have high levels of oxygen as it will reduce their natural drive to breathe. Clients with COPD often require steroid treatment such as Methylprednisone. Ambulating the client in the hallways is acceptable. The client may need to be on continuous pulse ox symmetry.
Subcategory – Management of Care
Rationale – A client with COPD should not have high levels of oxygen as it will reduce their natural drive to breathe. Clients with COPD often require steroid treatment such as Methylprednisone. Ambulating the client in the hallways is acceptable. The client may need to be on continuous pulse ox symmetry.
Subcategory – Management of Care
What roles would be utilized by an informatics nurse? Select all that apply.
Rationale – The informatics nurse asks for liaison between the clinical and technological departments. They are responsible for testing information systems as well as training staff. They do not repair software programs and are not responsible for the installation of hardware.
Subcategory – Information Technology
Rationale – The informatics nurse asks for liaison between the clinical and technological departments. They are responsible for testing information systems as well as training staff. They do not repair software programs and are not responsible for the installation of hardware.
Subcategory – Information Technology
What finding should be reported to the healthcare provider first?
Rationale – A digoxin level greater than 2.0 mg/dL is a critical value and should be reported to the health care provider immediately. The platelet count is slightly low but not critical. The white blood cell count is slightly elevated but not critical and the Dilantin level is normal.
Subcategory – Collaboration with Interdisciplinary Team
Rationale – A digoxin level greater than 2.0 mg/dL is a critical value and should be reported to the health care provider immediately. The platelet count is slightly low but not critical. The white blood cell count is slightly elevated but not critical and the Dilantin level is normal.
Subcategory – Collaboration with Interdisciplinary Team
A client is admitted to the emergency department with a potassium level of 6.5 mEq/L, a calcium level of 8.0 mg/dL, glucose level of 360 and a BUN of 50 mg/dL. What medication should the nurse administer first?
Rationale – Insulin will facilitate the uptake of glucose into the cell which will bring potassium with it. Kayexalate will work but is not the best option for acute treatment. Magnesium sulfate has been shown to treat overdose of slow release oral potassium but is not the priority medication.
Subcategory – Establishing Priorities
Rationale – Insulin will facilitate the uptake of glucose into the cell which will bring potassium with it. Kayexalate will work but is not the best option for acute treatment. Magnesium sulfate has been shown to treat overdose of slow release oral potassium but is not the priority medication.
Subcategory – Establishing Priorities
A client is brought to the emergency department after experiencing an electrical shock. What action by the nurse is priority?
Rationale- It is important to place the client on cardiac telemetry to identify any cardiac arrhythmias, a major complication of electrical shocks. The vital signs should be assessed once the client is on telemetry. The IV needs to be inserted, but is not priority over ECG monitoring. A full cardiac assessment is not priority.
Rationale- It is important to place the client on cardiac telemetry to identify any cardiac arrhythmias, a major complication of electrical shocks. The vital signs should be assessed once the client is on telemetry. The IV needs to be inserted, but is not priority over ECG monitoring. A full cardiac assessment is not priority.
A pediatric nurse is caring for the following for clients. Which client should the nurse see first?
Rationale – A child that is undergone a tonsillectomy with frequent swallowing has signs and symptoms of acute bleeding and should be assessed right away. A stoma that is dark red is a normal and expected finding. The child with bacterial meningitis would be expected to have an elevated temperature in can be seen after the postoperative child the scene. The child with protein in their urine with nephrotic syndrome is not priority.
Subcategory – Priorities
Rationale – A child that is undergone a tonsillectomy with frequent swallowing has signs and symptoms of acute bleeding and should be assessed right away. A stoma that is dark red is a normal and expected finding. The child with bacterial meningitis would be expected to have an elevated temperature in can be seen after the postoperative child the scene. The child with protein in their urine with nephrotic syndrome is not priority.
Subcategory – Priorities
A client is brought to the emergency department after experiencing an electrical shock. What action by the nurse is priority?
Rationale – Priority intervention for a client who is undergone an electrical shock is pleasing the client on cardiac monitoring to assess for any cardiac arrhythmias. The cardiac assessment would be the last priority. After placing the client on monitor vital sign should be obtained and are peripheral IV inserted.
Subcategory – Priorities
Rationale – Priority intervention for a client who is undergone an electrical shock is pleasing the client on cardiac monitoring to assess for any cardiac arrhythmias. The cardiac assessment would be the last priority. After placing the client on monitor vital sign should be obtained and are peripheral IV inserted.
Subcategory – Priorities
A nurse is preparing to administer and immunization via intramuscular route to a three-year-old. What action should the nurse implement first?
The nurse should explain the procedure to the child prior to the procedure occurring. The parents should not be holding the child’s leg. Demonstrating the procedure on a doll may further upset the child. Having a staff member there to hold a child or distract the child is appropriate but not the first priority.
Subcategory – Establishing Priorities
The nurse should explain the procedure to the child prior to the procedure occurring. The parents should not be holding the child’s leg. Demonstrating the procedure on a doll may further upset the child. Having a staff member there to hold a child or distract the child is appropriate but not the first priority.
Subcategory – Establishing Priorities
What tasks can a registered nurse assigned to a licensed vocational nurse when caring for a client who has just undergone a right hip replacement?
Rationale – The license vocational nurse can be asked to remind the client not to cross their legs. The licensed vocational nurse cannot administer IV morphine. Assessment of pulses needs to be done by a registered nurse. Passive range of motion should not be done on the affected leg.
Subcategory – Delegation
Rationale – The license vocational nurse can be asked to remind the client not to cross their legs. The licensed vocational nurse cannot administer IV morphine. Assessment of pulses needs to be done by a registered nurse. Passive range of motion should not be done on the affected leg.
Subcategory – Delegation
While caring for a client in labor the nurse recognizes late decelerations on the fetal monitor. What action by the nurse is priority?
Rationale – A client with late decelerations on the fetal monitor should be placed on their left side. The healthcare provider may be notified after the client is placed on the left side. Oxygen should be administered after the client’s position is changed however a facemask or higher concentration is indicated. IV fluids may be increased however this would be done after the position change and oxygen administration.
Subcategory- Establishing Priorities
Rationale – A client with late decelerations on the fetal monitor should be placed on their left side. The healthcare provider may be notified after the client is placed on the left side. Oxygen should be administered after the client’s position is changed however a facemask or higher concentration is indicated. IV fluids may be increased however this would be done after the position change and oxygen administration.
Subcategory- Establishing Priorities
The charge nurse is assigning clients in the labor and delivery unit. What client should be assigned to the most experienced nurse?
Rationale – Placental abruption places the mother and unborn child at significant risk for mortality because the abruption can extend it anytime very close monitoring is necessary. A fetal heart rate of 140 bpm as normal. The client scheduled for cesarean section does not need closer monitoring. A client at 32 weeks gestation diagnosed with cholelithiasis does not need the most experienced nurse.
Subcategory- Assignment, Delegation and Supervision
Rationale – Placental abruption places the mother and unborn child at significant risk for mortality because the abruption can extend it anytime very close monitoring is necessary. A fetal heart rate of 140 bpm as normal. The client scheduled for cesarean section does not need closer monitoring. A client at 32 weeks gestation diagnosed with cholelithiasis does not need the most experienced nurse.
Subcategory- Assignment, Delegation and Supervision
The nurse is assessing a postpartum client with heavy vaginal bleeding. The fundus is boggy and deviated to the left side even after fundal massage. What action by the nurse is priority?
Rationale – A client with a baggie fundus that is deviated to the left side even after final massage likely has a full bladder. The first action by the nurse should be to perform straight catheterization to empty the bladder. After emptying the bladder the fundus should continue to be massage. If the funder still does not form the healthcare provider should be notified. Pitocin may be indicated if the fundus does not firm up.
Subcategory- Establishing Priorities
Rationale – A client with a baggie fundus that is deviated to the left side even after final massage likely has a full bladder. The first action by the nurse should be to perform straight catheterization to empty the bladder. After emptying the bladder the fundus should continue to be massage. If the funder still does not form the healthcare provider should be notified. Pitocin may be indicated if the fundus does not firm up.
Subcategory- Establishing Priorities
The nurse overhears an unlicensed assistive personnel (UAP) discussing a client recently diagnosed with pancreatic cancer in the cafeteria with another unlicensed assistive personnel. What action by the nurse is most appropriate?
Rationale – The nurse should first address the person and ask that the conversation be stopped in the public place. Notifying the charge nurses appropriate after asking the UAP to stop the discussion. The situation does not need to be referred to the ethics board. The client does not need to be informed about the situation.
Subcategory- Confidentiality/Information Security
Rationale – The nurse should first address the person and ask that the conversation be stopped in the public place. Notifying the charge nurses appropriate after asking the UAP to stop the discussion. The situation does not need to be referred to the ethics board. The client does not need to be informed about the situation.
Subcategory- Confidentiality/Information Security
What action requires immediate intervention by the nurse manager of a medical surgical unit?
Rationale – Discussing a client’s condition in the hallway is a breach of confidentiality in violation of HIPAA. The LVN can check on apical pulses. A UAP can take vital signs on a newly admitted client. The LVN can administer IM injections including a pneumonia vaccine.
Subcategory- Concepts of Management
Rationale – Discussing a client’s condition in the hallway is a breach of confidentiality in violation of HIPAA. The LVN can check on apical pulses. A UAP can take vital signs on a newly admitted client. The LVN can administer IM injections including a pneumonia vaccine.
Subcategory- Concepts of Management
A client that has just been admitted with a diagnosis of cardiomyopathy requested do not resuscitate paperwork. The client completed the paperwork after the physician explained the advanced directive, the nurse witnessed it and the physician wrote the order. While the nurse was completing the paperwork the client stopped breathing and had no pulse. The nurse enters the room to find the healthcare team performing cardiopulmonary resuscitation. What action by the nurse is most appropriate?
Rationale – With the necessary paperwork in order the client’s wishes it should be adhered to in CPR should be stopped. The healthcare provider does not need to be notified. The health care proxy should not he asked overturn a DNR. A DNR would mean cessation of CPR and would not indicate continuing and avoiding intubation.
Subcategory-Advanced Directives
Rationale – With the necessary paperwork in order the client’s wishes it should be adhered to in CPR should be stopped. The healthcare provider does not need to be notified. The health care proxy should not he asked overturn a DNR. A DNR would mean cessation of CPR and would not indicate continuing and avoiding intubation.
Subcategory-Advanced Directives
What actions by the nurse may result in a malpractice? Select all that apply.
Rationale – Malpractice cases may be brought if incorrect dosages are given of a medication or a wrong medication is administered. Incorrectly interpreting medical orders may also lead to malpractice suits. Referring a case to the ethics board is not grounds for malpractice. Refusing to implement a questionable order is not grounds for malpractice.
Subcategory- Legal Rights and Responsibilities
Rationale – Malpractice cases may be brought if incorrect dosages are given of a medication or a wrong medication is administered. Incorrectly interpreting medical orders may also lead to malpractice suits. Referring a case to the ethics board is not grounds for malpractice. Refusing to implement a questionable order is not grounds for malpractice.
Subcategory- Legal Rights and Responsibilities
A client admitted to the emergency room for third-degree Chemical burns has a following orders. What order should the nurse implement first?
Rationale – A client with a chemical burn should have the burn irrigated immediately to remove any chemicals left in the burn. This will stop the burning process. After the burn is irrigated oxygen should be administered, IV should be placed and ringer’s lactate should be administered along with morphine. Respiratory assessment should then be done.
Subcategory-Establishing Priorities
Rationale – A client with a chemical burn should have the burn irrigated immediately to remove any chemicals left in the burn. This will stop the burning process. After the burn is irrigated oxygen should be administered, IV should be placed and ringer’s lactate should be administered along with morphine. Respiratory assessment should then be done.
Subcategory-Establishing Priorities
A nurse is working for an ophthalmology group. Which client warrants immediate intervention?
Rationale –A sudden shade coming over the vision is a sign of retinal detachment and needs immediate intervention. The client reporting halos is likely experiencing glaucoma. The client with dimming of the vision likely has cataracts. The client with a corneal abrasion is not priority over a client with a retinal detachment.
Subcategory- Establishing Priorities
Rationale –A sudden shade coming over the vision is a sign of retinal detachment and needs immediate intervention. The client reporting halos is likely experiencing glaucoma. The client with dimming of the vision likely has cataracts. The client with a corneal abrasion is not priority over a client with a retinal detachment.
Subcategory- Establishing Priorities
A client presents to the emergency department reporting an irregular heartbeat and shortness of breath. When placed on the monitor the nurse notes the client is in atrial fibrillation. What question by the nurse is priority?
Rationale- The priority question to ask a client with a new onset of atrial fibrillation is when the irregular rhythm began. This is important in determining if the client can be converted right away. It is important to ask if they have had the feeling before, if they are on blood thinners and about leg pain, but none of these questions are priority.
Subcategory- Establishing Priorities
Rationale- The priority question to ask a client with a new onset of atrial fibrillation is when the irregular rhythm began. This is important in determining if the client can be converted right away. It is important to ask if they have had the feeling before, if they are on blood thinners and about leg pain, but none of these questions are priority.
Subcategory- Establishing Priorities
What interventions are appropriate to delegate to a Licensed Vocational Nurse (LVN)? Select all that apply.
Rationale- Administration of a cleansing enema and IM morphine are within the scope of practice for an LVN. Discharge teaching and assessment require assessment, which is the role of the RN, not the LVN. Central venous catheter removal should not be done by an LVN.
Subcategory- Assignment, Delegation and Supervision
Rationale- Administration of a cleansing enema and IM morphine are within the scope of practice for an LVN. Discharge teaching and assessment require assessment, which is the role of the RN, not the LVN. Central venous catheter removal should not be done by an LVN.
Subcategory- Assignment, Delegation and Supervision
The nurse is caring for a client diagnosed with Reye’s syndrome. What medication order should the nurse question?
Rationale – Reye’s syndrome is caused by aspirin administration. It should not be administered. Acetaminophen, ibuprofen and diphenhydramine are not contraindicated.
Subcategory: Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Reye’s syndrome is caused by aspirin administration. It should not be administered. Acetaminophen, ibuprofen and diphenhydramine are not contraindicated.
Subcategory: Adverse Effects/Contraindications/Side Effects/Interactions
A client diagnosed with an ankle strain has been prescribed ibuprofen 800 mg orally every eight hours. What statement by the client indicates the need for further teaching?
Rationale – Ibuprofen should be administered with foods prevent gastric irritation. 2400 mg is the maximum dose of client should take in a 24 hour period of time hundred milligrams. The medication helps with inflammation and pain. The client should start to feel relief within 30 to 60 minutes of taking the medication.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Ibuprofen should be administered with foods prevent gastric irritation. 2400 mg is the maximum dose of client should take in a 24 hour period of time hundred milligrams. The medication helps with inflammation and pain. The client should start to feel relief within 30 to 60 minutes of taking the medication.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
The client was no history of diabetes is prescribed finger sticks every six hours. What medication does the nurse suspect the client has ordered?
Rationale – Methylprednisolone is a steroid the commonly causes an increase in blood sugar. The client will be placed on finger sticks to ensure the blood sugar is not elevated. If the client is not diabetic they would not likely be prescribed NovoLog unless the client has significant elevations from the steroids. Glucagon is an emergency treatment for hypoglycemia. Reglan administration does not cause blood sugar spike that would require finger sticks.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Methylprednisolone is a steroid the commonly causes an increase in blood sugar. The client will be placed on finger sticks to ensure the blood sugar is not elevated. If the client is not diabetic they would not likely be prescribed NovoLog unless the client has significant elevations from the steroids. Glucagon is an emergency treatment for hypoglycemia. Reglan administration does not cause blood sugar spike that would require finger sticks.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
A client diagnosed with atrial fibrillation is a heparin drip. What medication should the nurse ensure is available?
Rationale – Protamine sulfate is the antidote for heparin and should be available for any client sitting on heparin. Vitamin K is the antidote for warfarin. Warfarin will further increase the bleeding time. Diphenhydramine is not a priority medication to have available for a client receiving heparin.
Subcategory-Medication Administration
Rationale – Protamine sulfate is the antidote for heparin and should be available for any client sitting on heparin. Vitamin K is the antidote for warfarin. Warfarin will further increase the bleeding time. Diphenhydramine is not a priority medication to have available for a client receiving heparin.
Subcategory-Medication Administration
A client that is receiving warfarin therapy has an INR of 4.5. What action by the nurse is priority?
Rationale – The priority nursing intervention is the hold the warfarin. Reassessing the INR should be done at a later time is not priority. After holding the medications the prescriber should be notified of the critical value. Administering the medication will further elevate the INR level.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – The priority nursing intervention is the hold the warfarin. Reassessing the INR should be done at a later time is not priority. After holding the medications the prescriber should be notified of the critical value. Administering the medication will further elevate the INR level.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
A client prescribed digoxin received teaching from the nurse regarding this medication. What statement by the client indicates the teaching was effective?
Rationale – A client prescribed to Digoxin should notify the healthcare provider if they have a change in appetite, it is a sign up to digoxin toxicity. Color changes are not normal and should be reported. The client does not need to check their blood pressure every day. They may have more than 2 pounds in one week does not need to be reported in a client taking digoxin.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – A client prescribed to Digoxin should notify the healthcare provider if they have a change in appetite, it is a sign up to digoxin toxicity. Color changes are not normal and should be reported. The client does not need to check their blood pressure every day. They may have more than 2 pounds in one week does not need to be reported in a client taking digoxin.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
An average sized adult client is scheduled to receive subcutaneous heparin. What needle length is most appropriate for this injection?
Rationale – 5/8 inch is appropriate for a subcutaneous injection. 1 inch would be appropriate if the client was larger. A quarter inch needle is not long enough. One and a half inches is too long for any subcutaneous injection.
Subcategory-Parenteral/Intravenous
Rationale – 5/8 inch is appropriate for a subcutaneous injection. 1 inch would be appropriate if the client was larger. A quarter inch needle is not long enough. One and a half inches is too long for any subcutaneous injection.
Subcategory-Parenteral/Intravenous
A nurse is withdrawing medication from an ampule, what action by the nurse demonstrates a need for further teaching?
Rationale – If air is injected into an ampule, the medication will come out if the ampule is inverted. Air does not need to be injected. The nurse should use a filter needle when accessing and ampule. The ampule should be broken away from the body. The ampule can be inverted when withdrawing medication.
Subcategory-Parenteral/Intravenous Therapies
Rationale – If air is injected into an ampule, the medication will come out if the ampule is inverted. Air does not need to be injected. The nurse should use a filter needle when accessing and ampule. The ampule should be broken away from the body. The ampule can be inverted when withdrawing medication.
Subcategory-Parenteral/Intravenous Therapies
What action by the nurse is appropriate when drawing medication from two vials for a single injection?
Rationale – Air should be administered into both vials before withdrawing any medication. Injecting air and then medication in each vial risks contamination. The needle should be replaced before administering the medication. Medications should not be combined with in the vials, as this does not guarantee the proper dosage.
Subcategory-Parenteral/Intravenous Therapies
Rationale – Air should be administered into both vials before withdrawing any medication. Injecting air and then medication in each vial risks contamination. The needle should be replaced before administering the medication. Medications should not be combined with in the vials, as this does not guarantee the proper dosage.
Subcategory-Parenteral/Intravenous Therapies
A client is scheduled to receive 3 ml’s of morphine intramuscular. Which site is most appropriate for administration of this medication?
Rationale – Ventrogluteal is the preferred site for intramuscular injections. The deltoid muscle is not large enough for the administration of 3 mL of fluid. The dorsogluteal site is contraindicated for use due to risk of injury to nerves. The vastus lateralis is not a preferred site.
Subcategory-Parenteral/Intravenous Therapies
Rationale – Ventrogluteal is the preferred site for intramuscular injections. The deltoid muscle is not large enough for the administration of 3 mL of fluid. The dorsogluteal site is contraindicated for use due to risk of injury to nerves. The vastus lateralis is not a preferred site.
Subcategory-Parenteral/Intravenous Therapies
What action by the nurse is priority when accessing a peripherally inserted intermittent venous access device that does not have IV fluids running?
Rationale- The insertion site should be assessed prior to any other action. If there is redness, swelling or pain, the site should be further assessed and possibly discontinued. Once the site is found to be free of complications, the nurse should assess allergies, prepare medications and then flush prior to administering.
Subcategory-Parenteral/Intravenous Therapies
Rationale- The insertion site should be assessed prior to any other action. If there is redness, swelling or pain, the site should be further assessed and possibly discontinued. Once the site is found to be free of complications, the nurse should assess allergies, prepare medications and then flush prior to administering.
Subcategory-Parenteral/Intravenous Therapies
When mixing a medication to be administered intravenously, what information must be included on the label? Select all that apply.
Rationale- Anytime a nurse mixes a medication, they should label the solution with the client’s name, dilutent and they should include their initials. The prescriber’s name does not need to be included on the label. The dilutent manufacturer does not need to be added to the label.
Subcategory-Parenteral/Intravenous Therapies
Rationale- Anytime a nurse mixes a medication, they should label the solution with the client’s name, dilutent and they should include their initials. The prescriber’s name does not need to be included on the label. The dilutent manufacturer does not need to be added to the label.
Subcategory-Parenteral/Intravenous Therapies
A client has just had a subclavian non-tunneled central venous access device placed. The client reports shortness of breath and inability to take a deep breath. The client’s blood pressure is 108/52, pulse 105, respiratory rate 28, oxygen saturation 90% on room air. After contacting the healthcare provider, what action by the nurse is priority? Select all that apply.
Rationale – The client is exhibiting signs and symptoms of a pneumothorax which is a complication of the insertion of a central venous access device. The client should be placed in Fowler’s physician and the nurse should prepare for a thoracentesis. A cardiac assessment is not priority. The central line should not be removed or flushed.
Subcategory-Central Venous Access Device
Rationale – The client is exhibiting signs and symptoms of a pneumothorax which is a complication of the insertion of a central venous access device. The client should be placed in Fowler’s physician and the nurse should prepare for a thoracentesis. A cardiac assessment is not priority. The central line should not be removed or flushed.
Subcategory-Central Venous Access Device
A nurse has received teaching regarding production of infection with central venous access device. What actions by the nurse demonstrate the need for further teaching? Select all that apply.
Rationale – The central line catheter hub should not be wiped it with a 2×2. After cleansing it should be allowed to drive by air. The nurse should scrub the hub for a minimum of 15 seconds. The central line dressing should not be changed every shift. The dressing should be changed when soiled and per facility protocol. Solutions should be inspected prior to administering. Sterile technique should be maintained when changing tubing accessing the line and changing the dressing.
Subcategory-Central Venous Access Device
Rationale – The central line catheter hub should not be wiped it with a 2×2. After cleansing it should be allowed to drive by air. The nurse should scrub the hub for a minimum of 15 seconds. The central line dressing should not be changed every shift. The dressing should be changed when soiled and per facility protocol. Solutions should be inspected prior to administering. Sterile technique should be maintained when changing tubing accessing the line and changing the dressing.
Subcategory-Central Venous Access Device
A client receiving parenteral nutrition via a central venous catheter or notifies the nurse that the tube has become disconnected. The nurse suspects an air embolism. What position should the client be placed?
Rationale – A client suspected of having an air embolism should be placed on the left side with the head lower. Trendelenburg prone and high Fowlers are not indicated.
Subcategory-Central Venous Access Device
Rationale – A client suspected of having an air embolism should be placed on the left side with the head lower. Trendelenburg prone and high Fowlers are not indicated.
Subcategory-Central Venous Access Device
A client it is scheduled to receive antibiotic treatment via a central venous access device. The nurse notices the line is occluded when attempting to flush. What action by the nurse is appropriate?
Rationale – Alteplase is used to dissolve clots and central venous access devices. Instilling heparin will not dissolve a clot. The catheter should not be removed because one port is occluded. Utilizing a push pull method will push the clot into circulation and is contra indicated.
Subcategory-Central Venous Access Device
Rationale – Alteplase is used to dissolve clots and central venous access devices. Instilling heparin will not dissolve a clot. The catheter should not be removed because one port is occluded. Utilizing a push pull method will push the clot into circulation and is contra indicated.
Subcategory-Central Venous Access Device
The client is prescribed Piperacillin and tazobactam 3.375g in 50 mL of dextrose to infuse over 4 hours. What rate should the nurse set the pump? __________ mL/hr
Rationale- 50/4= 12.5
Subcategory-Dosage Calculations
Rationale- 50/4= 12.5
Subcategory-Dosage Calculations
A client is prescribed methylprednisolone 60 mg IV. The methylprednisolone is available in vials of 40 mg per 1mL. How many mLs should the nurse prepare? ________ mL.
Rationale: 60/40 x 1= 1.5
Subcategory-Dosage Calculations
Rationale: 60/40 x 1= 1.5
Subcategory-Dosage Calculations
A client is scheduled to receive pantoprazole 40 mg IV over 15 minutes. The medication has to be reconstituted in 10mLs of 0.9% sodium chloride. What rate should the nurse set the pump? _________ mL/hour.
Rationale: 60min/15min= 4x10mLs= 40 mL/hr
Subcategory-Dosage Calculations
Rationale: 60min/15min= 4x10mLs= 40 mL/hr
Subcategory-Dosage Calculations
Propofol 2.5mg/kg is ordered for a child weighing 28.6 lb. Propofol is available as 10mg/mL. How many mL must the nurse administer? _______ mL.
Rationale- 2.5*13= 32.5 mg 32=10x 32.5/10= 3.25 mL
Subcategory-Dosage Calculations
Rationale- 2.5*13= 32.5 mg 32=10x 32.5/10= 3.25 mL
Subcategory-Dosage Calculations
A client is scheduled to receive a transfusion of packed red blood cells. The recipient blood type is O. What donor blood types with the recipient be able to receive?
Rationale- O recipients can only receive O donor blood. They cannot receive A, B or AB blood.
Subcategory-Blood and blood products
Rationale- O recipients can only receive O donor blood. They cannot receive A, B or AB blood.
Subcategory-Blood and blood products
A client receiving a blood transfusion begins to have flushing and mild itching 20 minutes after the infusion has started. What action by the nurse is appropriate?
Rationale – The client is exhibiting a mild allergic reaction that can be treated by giving an antihistamine and restarting the transfusion slowly. Epinephrine is not indicated. A urine sample would only need to be sent if a hemolytic reaction occurred. The transfusion can be stopped to administer the antihistamine but normal saline does not need to be started.
Subcategory-Blood and blood products
Rationale – The client is exhibiting a mild allergic reaction that can be treated by giving an antihistamine and restarting the transfusion slowly. Epinephrine is not indicated. A urine sample would only need to be sent if a hemolytic reaction occurred. The transfusion can be stopped to administer the antihistamine but normal saline does not need to be started.
Subcategory-Blood and blood products
What action by the nurse is priority in a client is scheduled to have a blood transfusion and has a history of a febrile nonhemolytic transfusion reaction?
Rationale – An antipyretic should be administered to a client that is scheduled to have a blood transfusion who has a history of febrile nonhemolytic transfusion reaction. Antihistamines and glucocorticoids are not indicated. Antihypertensive will not prevent or decrease the effects of this reaction.
Subcategory- Blood and blood products
Rationale – An antipyretic should be administered to a client that is scheduled to have a blood transfusion who has a history of febrile nonhemolytic transfusion reaction. Antihistamines and glucocorticoids are not indicated. Antihypertensive will not prevent or decrease the effects of this reaction.
Subcategory- Blood and blood products
A client is experiencing acute intravascular hemolysis while receiving a blood transfusion. What medications does the nurse anticipate administering? Select all that apply.
Rationale – The nurse would anticipate administering vasopressors, corticosteroids and antihistamines to a client that is experiencing acute intravascular hemolysis when receiving a blood transfusion. Anti-medics and salicylates will not treat this reaction.
Subcategory-Blood and Blood Products
Rationale – The nurse would anticipate administering vasopressors, corticosteroids and antihistamines to a client that is experiencing acute intravascular hemolysis when receiving a blood transfusion. Anti-medics and salicylates will not treat this reaction.
Subcategory-Blood and Blood Products
What statement by a client diagnosed with general anxiety disorder that is prescribed alprazolam indicates a need for further teaching?
Rationale – Alprazolam can lead to dependency. The medication is taken when the client feels anxious. They should not drive on the medication. Orthostatic hypotension is a side effect of alprazolam so client should be instructed to get up slowly.
Subcategory-Expected Actions/Outcomes
Rationale – Alprazolam can lead to dependency. The medication is taken when the client feels anxious. They should not drive on the medication. Orthostatic hypotension is a side effect of alprazolam so client should be instructed to get up slowly.
Subcategory-Expected Actions/Outcomes
A client diagnosed with major depressive disorder is prescribed fluoxetine. What symptoms should the psychiatric nurse report immediately? Select all that apply.
Rationale – Ataxia, confusion and sweating are all signs of serotonin syndrome which is a serious complication of SSRIs such as fluoxetine. Hypertension and elevated temperature are common findings not hypotension or decrease temperature.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Ataxia, confusion and sweating are all signs of serotonin syndrome which is a serious complication of SSRIs such as fluoxetine. Hypertension and elevated temperature are common findings not hypotension or decrease temperature.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
A 15-year-old client is being treated for acne. What medications to the nurse anticipate being ordered? Select all that apply.
Rationale- Tetracycline, Metronidazole, and Benzoyl peroxide are medications used to treat acne. Levaquin and Fluocinolone are not used in the treatment of acne.
Subcategory-Medication Administration
Rationale- Tetracycline, Metronidazole, and Benzoyl peroxide are medications used to treat acne. Levaquin and Fluocinolone are not used in the treatment of acne.
Subcategory-Medication Administration
A client admitted for acute alcohol withdrawal has a blood pressure of 149/95, pulse of 10 wait a temperature of 101.2°F and moderate tremors. What medication order does the nurse anticipate?
Rationale– Lorazepam is used to treat acute alcohol withdrawal. All of the client’s vital signs are consistent with alcohol withdrawal, lorazepam would need to be administered. Metoprolol, acetaminophen, and diphenhydramine will not treat the alcohol withdrawal.
Subcategory-Medication Administration
Rationale– Lorazepam is used to treat acute alcohol withdrawal. All of the client’s vital signs are consistent with alcohol withdrawal, lorazepam would need to be administered. Metoprolol, acetaminophen, and diphenhydramine will not treat the alcohol withdrawal.
Subcategory-Medication Administration
A client admitted for chemotherapy is experiencing anorexia. What medication should the nurse anticipate being ordered?
Rationale –Dronabinol is used in the treatment of anorexia. It is an appetite stimulant. Morphine, acetaminophen, and methotrexate will not increase appetite.
Subcategory-Medication Administration
Rationale –Dronabinol is used in the treatment of anorexia. It is an appetite stimulant. Morphine, acetaminophen, and methotrexate will not increase appetite.
Subcategory-Medication Administration
What lab value is priority to assessing a client prescribed hydrochlorothiazide?
Rationale- Potassium is a common electrolyte disturbance that occurs in clients on hydrochlorothiazide. BUN may be altered but potassium is priority. White blood count and troponin would not be affected.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
Rationale- Potassium is a common electrolyte disturbance that occurs in clients on hydrochlorothiazide. BUN may be altered but potassium is priority. White blood count and troponin would not be affected.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
A client prescribed lithium has received teaching regarding the medication. What selection indicates teaching was effective?
Rationale – A client that is prescribed lithium will need an increased sodium intake. Apricots and salad do not have increased sodium. Hot Dogs would have an increase all intake. Salt substitutes will be contraindicated.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – A client that is prescribed lithium will need an increased sodium intake. Apricots and salad do not have increased sodium. Hot Dogs would have an increase all intake. Salt substitutes will be contraindicated.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
A client diagnosed with heart failure has a following medications ordered: captopril 6.25 mg. Hydrochlorothiazide 25 mg. Digoxin 0.125 mg. potassium 20 mEq. Furosemide 40 mg. The client’s vital signs are: blood-pressure 95/50, pulse 62, and oxygen saturation 94% on 2 L of oxygen via nasal cannula. The client’s B-natriuretic peptide (BNP) is 4450 and potassium is 3.4 mEq/L. What medications should the nurse administer? Select all that apply.
Rationale – All of the medications are safe to administer except for the captopril. The captopril should be held as the blood pressure is under 100 systolic.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – All of the medications are safe to administer except for the captopril. The captopril should be held as the blood pressure is under 100 systolic.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
A diabetic client has recently been diagnosed with hypertension and prescribed metoprolol. The nurse instructs the client to monitor blood glucose more frequently. What is the rationale for this intervention?
Rationale –Client’s with diabetes who have hypertension and are taking beta blockers should more frequently monitor their blood glucose as beta blockers can mask the signs of hypoglycemia. Beta blockers do not cause hypoglycemia. Beta blockers do not interfere with insulin absorption. Beta blockers do not contain glucose.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
Rationale –Client’s with diabetes who have hypertension and are taking beta blockers should more frequently monitor their blood glucose as beta blockers can mask the signs of hypoglycemia. Beta blockers do not cause hypoglycemia. Beta blockers do not interfere with insulin absorption. Beta blockers do not contain glucose.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
A client diagnosed with gout is prescribed colchicine. What statement by the client indicates a need for further teaching?
Rationale – Diarrhea should be reported to the healthcare provider as this may indicate the medication dosage would need to be decreased. The medication will not decrease the uric acid levels in the urine or the serum. The medication would decrease swelling. The client will likely need increased doses to treat pain.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Diarrhea should be reported to the healthcare provider as this may indicate the medication dosage would need to be decreased. The medication will not decrease the uric acid levels in the urine or the serum. The medication would decrease swelling. The client will likely need increased doses to treat pain.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
A client diagnosed with Sjögren’s syndrome would likely be prescribed what medications to treat dry lacrimal glands? Select all that apply.
Rationale – Artificial tears and pilocarpine are used in the treatment of dry lacrimal gland. Timolol is a beta blocker that decreases production of fluid and would be contraindicated. Acetazolamide and Methazolamide are carbonic anhydrase inhibitors that also will decrease production of intraocular fluid.
Subcategory-Medication Administration
Rationale – Artificial tears and pilocarpine are used in the treatment of dry lacrimal gland. Timolol is a beta blocker that decreases production of fluid and would be contraindicated. Acetazolamide and Methazolamide are carbonic anhydrase inhibitors that also will decrease production of intraocular fluid.
Subcategory-Medication Administration
A pediatric client is scheduled for an IV catheter insertion prior to a minor surgical procedure. What action by the nurse is appropriate when the healthcare provider orders eutectic mixture of local anesthetics (EMLA) cream?
Rationale – EMLA cream is best administered an hour before the procedure to allow the medication time to work. The cream should be applied to the area of the injection is going to be made. The cream should only be applied to a small area. A warm compress or cold compress are contraindicated with this medication.
Subcategory-Pharmacological Pain Management
Rationale – EMLA cream is best administered an hour before the procedure to allow the medication time to work. The cream should be applied to the area of the injection is going to be made. The cream should only be applied to a small area. A warm compress or cold compress are contraindicated with this medication.
Subcategory-Pharmacological Pain Management
A client is being admitted after undergoing small bowel resection. The surgeon has ordered acetaminophen for pain in the immediate postoperative period. What route does the nurse anticipate administering the medication?
Rationale – Intravenous acetaminophen has been approved for treatment of pain and fever. It can be given in combination with other medications. A client that is immediately postoperative would not be receiving oral medications. A rectal administration would likely be contraindicated in a client who is had a bowel resection. Acetaminophen is not administered intranasally.
Subcategory-Pharmacological Pain Management
Rationale – Intravenous acetaminophen has been approved for treatment of pain and fever. It can be given in combination with other medications. A client that is immediately postoperative would not be receiving oral medications. A rectal administration would likely be contraindicated in a client who is had a bowel resection. Acetaminophen is not administered intranasally.
Subcategory-Pharmacological Pain Management
What opiate analgesic is preferred and clients who are hemodynamically unstable?
Rationale –Fentanyl is the preferred analgesic agents and clients were hemodynamically unstable because it has minimal hemodynamic adverse effects. Morphine, Hydromorphone and Toradol all have effects on the hemodynamic system.
Subcategory-Pharmacological Pain Management
Rationale –Fentanyl is the preferred analgesic agents and clients were hemodynamically unstable because it has minimal hemodynamic adverse effects. Morphine, Hydromorphone and Toradol all have effects on the hemodynamic system.
Subcategory-Pharmacological Pain Management
The nurse is preparing discharge teaching for a client that is newly diagnosed with benign prostatic hyperplasia (BPH). What medications does the nurse anticipate providing teaching for? Select all that apply.
Rationale – Finasteride, Terazosin and Tadalafil are all medications prescribed for BPH. Metoprolol is a beta blocker that is not used to treat BPH. Hydrochlorothiazide is not used for treatment of BPH.
Subcategory – Medication Administration
Rationale – Finasteride, Terazosin and Tadalafil are all medications prescribed for BPH. Metoprolol is a beta blocker that is not used to treat BPH. Hydrochlorothiazide is not used for treatment of BPH.
Subcategory – Medication Administration
What medication is administered to a client diagnosed with increased intracranial pressure to increase plasma expansion and produce an osmotic effect?
Rationale – A client with increased intracranial pressure would receive mannitol to increased plasma expansion and produce an osmotic effect.
Subcategory – Expected Actions/Outcomes
Rationale – A client with increased intracranial pressure would receive mannitol to increased plasma expansion and produce an osmotic effect.
Subcategory – Expected Actions/Outcomes
A client diagnosed has a new prescription for glyburide. What lab values our priority for the nurse to assess prior to administering? Select all that apply.
Rationale – Hemoglobin A1C and blood glucose are both indicators of the client’s response to therapy and should be evaluated prior to administering. Hypocalcemia is a common side effect of this medication and should be assessed prior to administering. Potassium and hematocrit levels will not be affected by this medication.
Subcategory – Expected Actions/Outcomes
Rationale – Hemoglobin A1C and blood glucose are both indicators of the client’s response to therapy and should be evaluated prior to administering. Hypocalcemia is a common side effect of this medication and should be assessed prior to administering. Potassium and hematocrit levels will not be affected by this medication.
Subcategory – Expected Actions/Outcomes
A client diagnosed with Addison’s disease has received teaching regarding medication therapy. What statement by the client indicates a need for further teaching?
Rationale – Client’s will not need to decrease their cortisol doses during times of stress, they often will need to increase them. Clients will take two thirds of the medication the morning and one third later in the afternoon. They will also take the fludrocortisone in the morning. When it is hot clients with Addison’s will often need to take salt additives.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Client’s will not need to decrease their cortisol doses during times of stress, they often will need to increase them. Clients will take two thirds of the medication the morning and one third later in the afternoon. They will also take the fludrocortisone in the morning. When it is hot clients with Addison’s will often need to take salt additives.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
A client is receiving total parenteral nutrition. What IV solution may be piggybacked to the total parental nutrition?
Rationale – The only IV that should be piggyback to total parenteral nutrition is lipids. Antibiotics, dextrose in a morphine drip should be administered through a different line.
Subcategory – Total Parenteral Nutrition
Rationale – The only IV that should be piggyback to total parenteral nutrition is lipids. Antibiotics, dextrose in a morphine drip should be administered through a different line.
Subcategory – Total Parenteral Nutrition
A client receiving total parenteral nutrition is suspected of having refeeding syndrome. What lab values are consistent with this diagnosis?
Rationale- Hypomagnesemia, Hypokalemia and hypophosphatemia are common findings in refeeding syndrome that is a complication of malnutrition and administration of TPN. The phosphate would not be high, the potassium would not be high in the sodium is not affected.
Subcategory – Total Parenteral Nutrition
Rationale- Hypomagnesemia, Hypokalemia and hypophosphatemia are common findings in refeeding syndrome that is a complication of malnutrition and administration of TPN. The phosphate would not be high, the potassium would not be high in the sodium is not affected.
Subcategory – Total Parenteral Nutrition
What action by the nurse is priority when preparing to administer total parenteral nutrition via a subclavian central venous catheter to a client?
Rationale – It is important to have an in-line filter attached to the IV tubing when administering total parenteral nutrition to a client. The infusion does not need to be started slowly. The client’s blood glucose does not need to be checked just prior to administering. The dextrose concentration may be greater than 10% when administering total parenteral nutrition through a central venous catheter.
Subcategory – Total Parenteral Nutrition
Rationale – It is important to have an in-line filter attached to the IV tubing when administering total parenteral nutrition to a client. The infusion does not need to be started slowly. The client’s blood glucose does not need to be checked just prior to administering. The dextrose concentration may be greater than 10% when administering total parenteral nutrition through a central venous catheter.
Subcategory – Total Parenteral Nutrition
A client diagnosed with herpes simplex virus would likely be prescribed what medication for treatment?
Rationale – Acyclovir is an antiviral agents that is often used for treatment of herpes simplex virus. Antibiotic therapy such as doxycycline, penicillin G and Azithromycin will not be effective in the treatment of herpes simplex virus.
Subcategory – Expected Outcomes
Rationale – Acyclovir is an antiviral agents that is often used for treatment of herpes simplex virus. Antibiotic therapy such as doxycycline, penicillin G and Azithromycin will not be effective in the treatment of herpes simplex virus.
Subcategory – Expected Outcomes
A client is brought to the Emergency Department in cardiac arrest. The monitor shows ventricular fibrillation. The patient has been defibrillated once. What is the most important next intervention that the nurse should expect?
Rationale – For the survival of the client, it is most important to resume high-quality CPR. The client will be defibrillated again but that is not the most important next intervention. Speaking with the family is important, but not at this time. Epinephrine will be the next drug of choice, however will not be circulated around the body therefore ineffective without chest compressions.
Subcategory – Medical Emergencies
Rationale – For the survival of the client, it is most important to resume high-quality CPR. The client will be defibrillated again but that is not the most important next intervention. Speaking with the family is important, but not at this time. Epinephrine will be the next drug of choice, however will not be circulated around the body therefore ineffective without chest compressions.
Subcategory – Medical Emergencies
The nurse is beginning an 8 hour shift. Place the following clients in the order in which the nurse should see them based on priority.
Rationale – Of these four patients, the postoperative patient with pain level of 8/10 is priority. Next would be the patient s/p total hip replacement with a low H & H as this could be a sign of bleeding and the nurse should assess the surgical site and vital signs. Next would be the diabetic patient who will require education and medication intervention. Last would be the patient being discharged and requiring teaching.
Subcategory – Illness Management
Rationale – Of these four patients, the postoperative patient with pain level of 8/10 is priority. Next would be the patient s/p total hip replacement with a low H & H as this could be a sign of bleeding and the nurse should assess the surgical site and vital signs. Next would be the diabetic patient who will require education and medication intervention. Last would be the patient being discharged and requiring teaching.
Subcategory – Illness Management
A client presents to the Emergency Department complaining of dizziness. The nurse notes upon his/her assessment that the client is pale, diaphoretic, and has 1+ peripheral pulses. The nurse obtains vital signs and notes the patient to have a mean arterial pressure (MAP) of 55. How does the nurse correctly interpret this data?
Rationale – Mean Arterial Pressure (MAP) is within normal limits when it is at least above 65. A client with a low MAP is most likely hypotensive and a MAP less than 60 puts the client at a very large risk for decreased perfusion to the kidneys resulting in an acute kidney injury. The decreased perfusion to their legs and feet is not the most correct interpretation of this data.
Subcategory – Hemodynamics
Rationale – Mean Arterial Pressure (MAP) is within normal limits when it is at least above 65. A client with a low MAP is most likely hypotensive and a MAP less than 60 puts the client at a very large risk for decreased perfusion to the kidneys resulting in an acute kidney injury. The decreased perfusion to their legs and feet is not the most correct interpretation of this data.
Subcategory – Hemodynamics
The client presents to the Emergency Department complaining of symptoms of hyperglycemia. Which of the following data most likely confirms a diagnosis of Diabetic Ketoacidosis (DKA)?
Rationale – While a diabetic patient having a hyperglycemic episode will have an elevated finger stick and may possibly have glucose in their urine, the lab value that more directly aids in the diagnosis is an elevated anion gap. An elevated WBC level does not directly apply.
Subcategory – Medical Emergencies
Rationale – While a diabetic patient having a hyperglycemic episode will have an elevated finger stick and may possibly have glucose in their urine, the lab value that more directly aids in the diagnosis is an elevated anion gap. An elevated WBC level does not directly apply.
Subcategory – Medical Emergencies
A client is newly diagnosed with atrial fibrillation. Which physician orders would the nurse question?
Rationale – The patient with atrial fibrillation is at high risk of clots forming in the atria and therefore must be anticoagulated. Lovenox is a simple low molecular weight heparin and should never be given at the same time as heparin as this could result in severe bleeding difficulties. Coumadin is expected to be given with other anti-coagulants with shorter half-lives until the Coumadin reaches a therapeutic level.
Subcategory – Illness Management
Rationale – The patient with atrial fibrillation is at high risk of clots forming in the atria and therefore must be anticoagulated. Lovenox is a simple low molecular weight heparin and should never be given at the same time as heparin as this could result in severe bleeding difficulties. Coumadin is expected to be given with other anti-coagulants with shorter half-lives until the Coumadin reaches a therapeutic level.
Subcategory – Illness Management
A client is admitted for hypoglycemia. What factor contributes to the nurse continuing to monitor lab values?
Rationale – An Acute Kidney Injury (AKI) secondary to dehydration is the number one sequelae for hospitalized patients. Hypoglycemic agents do not lose efficacy over time. Lab values for treatment compliance such as Hemoglobin A1C show glycemic control over time not acutely. The hospitalized patient is at risk for hyperglycemia, not hypoglycemia, due to body stress and medication management.
Subcategory – Pathophysiology
Rationale – An Acute Kidney Injury (AKI) secondary to dehydration is the number one sequelae for hospitalized patients. Hypoglycemic agents do not lose efficacy over time. Lab values for treatment compliance such as Hemoglobin A1C show glycemic control over time not acutely. The hospitalized patient is at risk for hyperglycemia, not hypoglycemia, due to body stress and medication management.
Subcategory – Pathophysiology
A client presents to the Emergency Department with RLE redness and pain and is diagnosed with cellulitis. The client is started on Vancomycin 1gm IV q 12 hours. What is the most important adverse reaction to monitor for during Vancomycin infusion?
Rationale – Vancomycin administration is solely linked to Red Man Syndrome, especially during a more rapid infusion. Hyperthermia and tachycardia are adverse reactions to many different medications, however not specifically to Vancomycin. While Steven Johnson Syndrome is possible with many antibiotics including Vancomycin, it is not the most directly related adverse reaction.
Subcategory – Unexpected Response to Therapy/Medical Emergencies
Rationale – Vancomycin administration is solely linked to Red Man Syndrome, especially during a more rapid infusion. Hyperthermia and tachycardia are adverse reactions to many different medications, however not specifically to Vancomycin. While Steven Johnson Syndrome is possible with many antibiotics including Vancomycin, it is not the most directly related adverse reaction.
Subcategory – Unexpected Response to Therapy/Medical Emergencies
A client is brought to the Emergency Department by his friends. He is unresponsive and diaphoretic. The friends do not stay long enough to give detailed information or health histories. The nurse knows to anticipate which of the following interventions. Select all that apply.
Rationale – With an unresponsive client dropped off in these circumstances, the nurse can anticipate checking a finger stick to rule out severe hypoglycemia/hyperglycemia. Obtaining blood work will help determine any obvious imbalances. Narcan will be administered as a drug overdose is likely and should be quickly ruled in or out. Epinephrine and an isolation room are not appropriate interventions for this client.
Subcategory – Medical Emergencies
Rationale – With an unresponsive client dropped off in these circumstances, the nurse can anticipate checking a finger stick to rule out severe hypoglycemia/hyperglycemia. Obtaining blood work will help determine any obvious imbalances. Narcan will be administered as a drug overdose is likely and should be quickly ruled in or out. Epinephrine and an isolation room are not appropriate interventions for this client.
Subcategory – Medical Emergencies
An adult client presents to the Emergency Department with mid-abdominal pain that radiates straight through their back. Based on this client’s presentation, the nurse will question which of the following orders?
Rationale- This client’s symptoms are most common with complications arising from an abdominal aortic aneurysm. The nurse should anticipate potential emergency surgery for this client and keep the client NPO. Therefore the nurse would question the aspirin order. NaCl, Morphine and ondansetron are appropriate orders.
Subcategory – Medical Emergencies
Rationale- This client’s symptoms are most common with complications arising from an abdominal aortic aneurysm. The nurse should anticipate potential emergency surgery for this client and keep the client NPO. Therefore the nurse would question the aspirin order. NaCl, Morphine and ondansetron are appropriate orders.
Subcategory – Medical Emergencies
A client is admitted to the hospital with a diagnosis of Cor Pulmonale. Which of the following body systems would the nurse include in the focused assessment?
Rationale – Cor Pulmonale is a disease process causing right-sided heart failure. While the disease can stem from a pulmonary complication, it is a disease of the heart. Therefore, though an assessment of the respiratory system is very important, cardiovascular system would be the focused assessment for this client. Integumentary and Neurovascular are important assessments, but not the focus with Cor Pulmonale.
Subcategory – Pathophysiology
Rationale – Cor Pulmonale is a disease process causing right-sided heart failure. While the disease can stem from a pulmonary complication, it is a disease of the heart. Therefore, though an assessment of the respiratory system is very important, cardiovascular system would be the focused assessment for this client. Integumentary and Neurovascular are important assessments, but not the focus with Cor Pulmonale.
Subcategory – Pathophysiology
The nurse is provided nutritional education to a client with an immunodeficiency. What selection I have a client indicates a need for further teaching?
Rationale – A fresh salad we increase the risk of exposure to pathogens. Canned soups, baked chicken and cottage cheese are all safe selections.
Subcategory- Physiological adaptation- illness management
Rationale – A fresh salad we increase the risk of exposure to pathogens. Canned soups, baked chicken and cottage cheese are all safe selections.
Subcategory- Physiological adaptation- illness management
A client is admitted to the medical/surgical unit status post Left total hip replacement. Routine labs on a client show an H&H of 8.5mg/dL & 22.1%. What focused assessment is priority?
Rationale- Any surgery involving a long bone such as the femur in a total hip replacement puts the client at an increased risk for bleeding. Assessing the surgical site for bleeding or hematoma would be the focused assessment for a postoperative client with low blood counts. Assessing the lungs, heart, and pedal pulses are all important, but not the focused assessment.
Subcategory- Hemodynamics
Rationale- Any surgery involving a long bone such as the femur in a total hip replacement puts the client at an increased risk for bleeding. Assessing the surgical site for bleeding or hematoma would be the focused assessment for a postoperative client with low blood counts. Assessing the lungs, heart, and pedal pulses are all important, but not the focused assessment.
Subcategory- Hemodynamics
A client on the medical/surgical floor shows an acute change in mental status. The nurse should assess for what electrolyte imbalance?
Rationale- A low sodium level can cause changes in mental status including confusion and combativeness. Changes in potassium, magnesium, and chloride do not directly manifest in mental status changes.
Subcategory- Fluid and Electrolyte Imbalances
Rationale- A low sodium level can cause changes in mental status including confusion and combativeness. Changes in potassium, magnesium, and chloride do not directly manifest in mental status changes.
Subcategory- Fluid and Electrolyte Imbalances
A client is newly diagnosed with Type 2 Diabetes has received discharge teaching. What statement by the client indicates a need for further teaching?
Rationale- Clients with Type 2 DM should be taught to check their blood sugar before each meal and at bedtime. The other statements are appropriate statements for a client who understands their Type 2 DM discharge teaching.
Subcategory- Illness Management
Rationale- Clients with Type 2 DM should be taught to check their blood sugar before each meal and at bedtime. The other statements are appropriate statements for a client who understands their Type 2 DM discharge teaching.
Subcategory- Illness Management
A woman is brought by ambulance to the hospital in active labor. Upon arrival in the Emergency Department (ED), she vaginally delivers a full-term female infant. Which is the priority nursing intervention for the newborn?
Rationale- The priority nursing intervention for a newborn is to assess heart rate and respiratory status. After this is completed the cord may be checked. Establishing feeding and palpating fundal height are not priority.
Subcategory – Emergencies
Rationale- The priority nursing intervention for a newborn is to assess heart rate and respiratory status. After this is completed the cord may be checked. Establishing feeding and palpating fundal height are not priority.
Subcategory – Emergencies
A client diagnosed with hypoparathyroidism would likely have what clinical findings? Select all that apply.
Rationale – Hair loss, decreased cardiac output and malabsorption are all common findings and client’s diagnosis parathyroidism. Polyuria is also common and clients with hyperparathyroidism. Constipation is common with hyperparathyroidism.
Subcategory – Alterations in Body Systems
Rationale – Hair loss, decreased cardiac output and malabsorption are all common findings and client’s diagnosis parathyroidism. Polyuria is also common and clients with hyperparathyroidism. Constipation is common with hyperparathyroidism.
Subcategory – Alterations in Body Systems
The client reports to their primary care provider with non-painful dimpling in one breast. What possible cause does the nurse suspect?
Rationale – Non-painful dimpling of the breast is suggestive of a neoplasm it needs to be diagnosed promptly. Infection of mastitis would be painful. Fibrocystic changes would result in a lump.
Subcategory – Alterations in Body Systems
Rationale – Non-painful dimpling of the breast is suggestive of a neoplasm it needs to be diagnosed promptly. Infection of mastitis would be painful. Fibrocystic changes would result in a lump.
Subcategory – Alterations in Body Systems
The client reports to the emergency department with unilateral bulging in the groin when straining. What abnormality does the nurse suspect?
Rationale – Bilateral bulging of the groin while streaming is a common symptom of an inguinal hernia. A tumor would not likely only present with straining and present as swelling. A chancroid is a papular irregularly shaped and would have pus. Epididymis would be painful.
Subcategory – Medical Emergencies
Rationale – Bilateral bulging of the groin while streaming is a common symptom of an inguinal hernia. A tumor would not likely only present with straining and present as swelling. A chancroid is a papular irregularly shaped and would have pus. Epididymis would be painful.
Subcategory – Medical Emergencies
A client diagnosed with breast cancer has a tumor with lymph node involvement but no metastasis. What stage is the client’s breast cancer?
Rationale – Stage III breast cancer is cancer with a tumor that has a lymph node involvement and has not metastasized.
Subcategory – Alterations in Body System
Rationale – Stage III breast cancer is cancer with a tumor that has a lymph node involvement and has not metastasized.
Subcategory – Alterations in Body System
A client diagnosed with chlamydia has received teaching regarding this diagnosis. What statement by the client indicates the teaching was effective?
Rationale – Abstinence from sexual activities for one week is indicated in a client with a positive diagnosis of chlamydia. It is common for people who have contracted chlamydia to be re-infected again. It is possible to contract chlamydia even if using a condom. Antibiotic therapy does not cure chlamydia until it has been taken for a period of time and it is indicated to finish it.
Subcategory – Illness Management
Rationale – Abstinence from sexual activities for one week is indicated in a client with a positive diagnosis of chlamydia. It is common for people who have contracted chlamydia to be re-infected again. It is possible to contract chlamydia even if using a condom. Antibiotic therapy does not cure chlamydia until it has been taken for a period of time and it is indicated to finish it.
Subcategory – Illness Management
The client diagnosed with a cystocele should be monitored for what complication?
Rationale – A cystocele may prevent a woman from having complete bladder emptying. This increases the risk of bladder infection. Uterine bleeding, fistulas and rectal prolapse are not common complications of a cystocele.
Subcategory – Illness Management
Rationale – A cystocele may prevent a woman from having complete bladder emptying. This increases the risk of bladder infection. Uterine bleeding, fistulas and rectal prolapse are not common complications of a cystocele.
Subcategory – Illness Management
The nurse is caring for a client on a ventilator and the low volume alarm has continued to go off. The nurse cannot find an area where the tubing is disconnected or why the alarm is sounding. The client is tachypneic and the oxygen saturation is beginning to lower. What action should the nurse take first?
Rationale – If a client is not receiving breathe or oxygen the most important thing for the nurse to do is to bag the client until help arrives. The ventilator should not be reset. Respiratory therapy and the healthcare provider should be notified, however the nurse should first bag the client.
Subcategory – Medical Emergencies
Rationale – If a client is not receiving breathe or oxygen the most important thing for the nurse to do is to bag the client until help arrives. The ventilator should not be reset. Respiratory therapy and the healthcare provider should be notified, however the nurse should first bag the client.
Subcategory – Medical Emergencies
A client with early hypoxia would likely demonstrate what signs and symptoms? Select all that apply.
Rationale – Restlessness and tachypnea are signs of early hypoxia. Hypotension and cyanosis later signs of hypoxia. Bradycardia is not a sign of hypoxia.
Subcategory – Alterations in Body Systems
Rationale – Restlessness and tachypnea are signs of early hypoxia. Hypotension and cyanosis later signs of hypoxia. Bradycardia is not a sign of hypoxia.
Subcategory – Alterations in Body Systems
An older adult client reports to the emergency room with cough, shaking and pleuritic chest pain. The client’s blood pressure is 128/68, pulse 106 respiratory rate 28 oxygen saturation is 91% on room air and temperature is 101.9°F. The client was hospitalized 30 days ago for heart failure. The chest x-ray shows pneumonia in the right lower lobe. What intervention by the nurse is priority?
Rationale – A sputum culture is a priority intervention for a client that is diagnosed with pneumonia. Antibiotics should not be hung until after the cultures obtained. Acetaminophen may be given however priority would be the sputum culture. Continuous oxygen monitoring is not indicated.
Subcategory – Medical Emergencies
Rationale – A sputum culture is a priority intervention for a client that is diagnosed with pneumonia. Antibiotics should not be hung until after the cultures obtained. Acetaminophen may be given however priority would be the sputum culture. Continuous oxygen monitoring is not indicated.
Subcategory – Medical Emergencies
Which client is at greatest risk for developing pneumonia?
Rationale – The 24-year-old has multiple risk factors including IV drug use, recent antibiotics and recent infection. The 72-year-old client is at risk because of age. The 55-year-old is at risk because of history of alcoholism. The 60-year-old paraplegic a client has immobility as a risk factor.
Subcategory – Alterations in Body Systems
Rationale – The 24-year-old has multiple risk factors including IV drug use, recent antibiotics and recent infection. The 72-year-old client is at risk because of age. The 55-year-old is at risk because of history of alcoholism. The 60-year-old paraplegic a client has immobility as a risk factor.
Subcategory – Alterations in Body Systems
What interventions are appropriate for a client diagnosed with Paget’s disease? Select all that apply.
Rationale –Administration of ibuprofen, Application of heat and Alendronate administration are all indicated for clients with Paget’s disease. Calcium should be increased not restricted. Protein should be increased not restricted.
Subcategory – Illness Management
Rationale –Administration of ibuprofen, Application of heat and Alendronate administration are all indicated for clients with Paget’s disease. Calcium should be increased not restricted. Protein should be increased not restricted.
Subcategory – Illness Management
Which client has the greatest risk factor for development of osteoporosis?
Rationale – Female’s that are Caucasian and Asian-American have higher incidence of osteoporosis. The client is also greater than 65 years of age and postmenopausal two additional risk factors. The 58-year-old Asian American woman with a sedentary lifestyle is under the age of 65 so only has sedentary lifestyle as a risk factor. The 72-year-old need of American male client who drinks one beer a day has only age as a risk factor. The 70-year-old African-American client has a history of smoking is not a current smoker.
Subcategory – Pathophysiology
Rationale – Female’s that are Caucasian and Asian-American have higher incidence of osteoporosis. The client is also greater than 65 years of age and postmenopausal two additional risk factors. The 58-year-old Asian American woman with a sedentary lifestyle is under the age of 65 so only has sedentary lifestyle as a risk factor. The 72-year-old need of American male client who drinks one beer a day has only age as a risk factor. The 70-year-old African-American client has a history of smoking is not a current smoker.
Subcategory – Pathophysiology
What finding should be reported immediately and a client diagnosed with ulcerative colitis?
Rationale – A board like abdomen is a sign of acute abdominal bleeding and needs to be reported immediately. Vomiting can be treated with an anti-emetic and a call should be placed if one is not ordered. Blood in the stool can be a normal finding with this diagnosis. Abdominal pain of seven out of 10 maybe treated with pain medication.
Subcategory – Alterations in Body Systems
Rationale – A board like abdomen is a sign of acute abdominal bleeding and needs to be reported immediately. Vomiting can be treated with an anti-emetic and a call should be placed if one is not ordered. Blood in the stool can be a normal finding with this diagnosis. Abdominal pain of seven out of 10 maybe treated with pain medication.
Subcategory – Alterations in Body Systems
A client diagnosed with heart failure is being evaluated to determine the effectiveness of the current oxygen therapy. The client ABGs are pH of 7.35, PaO2 of 105. PaCO2 of 48. The client’s vital signs are blood-pressure 108/62, pulse of 64, respiratory rate of 25, oxygen saturation of 94% on 3L. What order does the nurse expect to receive from the healthcare provider?
Rationale – The client’s pH is in the normal range, the PaO2 is slightly elevated although the oxygen saturation is only 94% on 3L. The client is breathing more rapidly and may blow off the PaCo2 themselves. Intubation is not indicated. A non-rebreather mask is not indicated.
Subcategory – Illness Management
Rationale – The client’s pH is in the normal range, the PaO2 is slightly elevated although the oxygen saturation is only 94% on 3L. The client is breathing more rapidly and may blow off the PaCo2 themselves. Intubation is not indicated. A non-rebreather mask is not indicated.
Subcategory – Illness Management
What findings are consistent with a client who has had diarrhea for several days?
Rationale – A client with diarrhea for several days would likely be experiencing metabolic acidosis. This would involve a low pH, a low bicarbonate. The sodium and potassium levels are normal at 135 and 4.9 mEq/L.
Subcategory – Fluid and Electrolyte Imbalances
Rationale – A client with diarrhea for several days would likely be experiencing metabolic acidosis. This would involve a low pH, a low bicarbonate. The sodium and potassium levels are normal at 135 and 4.9 mEq/L.
Subcategory – Fluid and Electrolyte Imbalances
What findings does a nurse suspect in a client diagnosed with Graves disease? Select all that apply.
Rationale- Palpitations, diaphoresis and ophthalmopathy are common findings in a client diagnosed with thyroid hyperfunction, Graves disease. Weight gain and cold skin would be found in hypofunction, not hyperfunction.
Subcategory – Alterations in Body Systems
Rationale- Palpitations, diaphoresis and ophthalmopathy are common findings in a client diagnosed with thyroid hyperfunction, Graves disease. Weight gain and cold skin would be found in hypofunction, not hyperfunction.
Subcategory – Alterations in Body Systems
What intervention is priority for a client with a blood glucose of 48 who has palpitations, shakiness and is diaphoretic?
Rationale – A client who is conscious with a low blood glucose level should be given an oral carbohydrate snack. IV dextrose would be started if necessary after an emergency intervention such as D50 IV. Subcutaneous glucagon should be given if they cannot take anything orally. Administering a rapid acting insulin is contraindicated in this client.
Subcategory – Medical Emergencies
Rationale – A client who is conscious with a low blood glucose level should be given an oral carbohydrate snack. IV dextrose would be started if necessary after an emergency intervention such as D50 IV. Subcutaneous glucagon should be given if they cannot take anything orally. Administering a rapid acting insulin is contraindicated in this client.
Subcategory – Medical Emergencies
What finding is consistent with a client diagnosed with a spinal cord injury at the level of T4?
Rationale – A client with an injury between T1 and T2 five would experience paraplegia with sensation present down to the nipple mine.
Subcategory – Alterations in Body Systems
Rationale – A client with an injury between T1 and T2 five would experience paraplegia with sensation present down to the nipple mine.
Subcategory – Alterations in Body Systems
What type of seizure is characterized by seizures that become continuous with very short non-seizure periods between them?
Rationale – Status epilepticus is a seizure that become continuous with only short periods of cessation.
Subcategory – Medical Emergencies
Rationale – Status epilepticus is a seizure that become continuous with only short periods of cessation.
Subcategory – Medical Emergencies
What treatment is used to remove IgG antibodies in a client diagnosed with myasthenia gravis?
Rationale – Plasmapheresis is used to remove IgG antibodies from a client diagnosed with myasthenia gravis. Immunosuppressants, Anti-cholinesterase and Thymectomy will not be used to decrease the IgG levels.
Subcategory – Illness Management
Rationale – Plasmapheresis is used to remove IgG antibodies from a client diagnosed with myasthenia gravis. Immunosuppressants, Anti-cholinesterase and Thymectomy will not be used to decrease the IgG levels.
Subcategory – Illness Management
What nursing interventions should be avoided in a client diagnosed with increased intracranial pressure? Select all that apply.
Rationale – A client with ICP should not have neck flexion or narcotics which can mask the signs of increased ICP. They can have stool softeners. Clients can be suction for up to 10 seconds. Hyperventilation is a normal treatment for clients with increased ICP.
Subcategory – Illness Management
Rationale – A client with ICP should not have neck flexion or narcotics which can mask the signs of increased ICP. They can have stool softeners. Clients can be suction for up to 10 seconds. Hyperventilation is a normal treatment for clients with increased ICP.
Subcategory – Illness Management
What sign is an early indicator of increased intracranial pressure?
Rationale- Ptosis is an early sign of intracranial pressure increases. A widening pulse pressure and non-reactive pupil are later signs of increased intracranial pressure. The ipsilateral pupil would be dilated, not constricted.
Subcategory- Alterations in Body Systems
Rationale- Ptosis is an early sign of intracranial pressure increases. A widening pulse pressure and non-reactive pupil are later signs of increased intracranial pressure. The ipsilateral pupil would be dilated, not constricted.
Subcategory- Alterations in Body Systems
A client diagnosed with hepatic encephalopathy has an ammonia level of 220 mcg/dL. The client is confused and disoriented. What action by the nurse is priority?
Rationale- The treatment for hepatic encephalopathy is rectal lactulose. Vital signs should be obtained after the medication is ordered. Restraints are not necessary if the client’s confusion resolves from the lactulose. A full neurological exam may be done after the medication is administered, it is not priority.
Subcategory- Illness Management
Rationale- The treatment for hepatic encephalopathy is rectal lactulose. Vital signs should be obtained after the medication is ordered. Restraints are not necessary if the client’s confusion resolves from the lactulose. A full neurological exam may be done after the medication is administered, it is not priority.
Subcategory- Illness Management
A client admitted to the emergency room with a diagnosis of chest pain has an electrocardiogram that shows an elevated ST segment. The client has a negative troponin level. What actions by the nurse are priority? Select all that apply
Rationale- A client that is experiencing an acute myocardial infarction, which is demonstrated by the elevation in the ST segment should receive IV morphine, oxygen and aspirin. Placing the client in supine position may lead to difficulty breathing, the client should be in Fowler’s position. The troponin level should be repeated at the 6th hour.
Subcategory- Medical Emergencies
Rationale- A client that is experiencing an acute myocardial infarction, which is demonstrated by the elevation in the ST segment should receive IV morphine, oxygen and aspirin. Placing the client in supine position may lead to difficulty breathing, the client should be in Fowler’s position. The troponin level should be repeated at the 6th hour.
Subcategory- Medical Emergencies
A client diagnosed with a hiatal hernia reports increased pyrosis and dysphagia. What statement by the client indicates a need for further education?
Rationale- It is important for the client to avoid ibuprofen, which is not a treatment for pyrosis (heartburn). It is indicated to eat several smaller meals instead of large meals, five small meals is better to reduce symptoms. Ranitidine is indicated in treatment of a hiatal hernia. Caffeine should be avoided in clients with hiatal hernias.
Subcategory- Illness Management
Rationale- It is important for the client to avoid ibuprofen, which is not a treatment for pyrosis (heartburn). It is indicated to eat several smaller meals instead of large meals, five small meals is better to reduce symptoms. Ranitidine is indicated in treatment of a hiatal hernia. Caffeine should be avoided in clients with hiatal hernias.
Subcategory- Illness Management
A client diagnosed that has experienced a myocardial infarction is being evaluated for cardiogenic shock. What medication does the nurse recognize as masking the earliest signs of shock?
Rationale- Beta blockers slow the heart rate, which would be an early indication of shock. Beta blockers mask tachycardia. Ace inhibitors will not have much effect on the heart rate to mask shock. Glucocorticoids and potassium sparing diuretics do not influence heart rate.
Subcategory- Unexpected response to therapy
Rationale- Beta blockers slow the heart rate, which would be an early indication of shock. Beta blockers mask tachycardia. Ace inhibitors will not have much effect on the heart rate to mask shock. Glucocorticoids and potassium sparing diuretics do not influence heart rate.
Subcategory- Unexpected response to therapy
What assessment findings are consistent with left sided heart failure? Select all that apply.
Rationale- Restlessness, exertional dyspnea and shortness of breath are all signs of left sided heart failure. Ascites and dependent edema are signs of right sided heart failure.
Subcategory- Alterations in Body Systems
Rationale- Restlessness, exertional dyspnea and shortness of breath are all signs of left sided heart failure. Ascites and dependent edema are signs of right sided heart failure.
Subcategory- Alterations in Body Systems
What lab value should be reported immediately in a client receiving furosemide that is scheduled to begin digoxin?
Rationale- Hypokalemia should be reported and treated prior to administration of digoxin therapy. The combination of these medications lead to hypokalemia. The sodium, calcium and magnesium levels are all normal.
Subcategory- Unexpected Response to Therapy
Rationale- Hypokalemia should be reported and treated prior to administration of digoxin therapy. The combination of these medications lead to hypokalemia. The sodium, calcium and magnesium levels are all normal.
Subcategory- Unexpected Response to Therapy
What IV fluid order should be questioned in a client with the following labs: Sodium 150 mEq/L, Potassium 3.5 mEq/L and chloride of 100 mEq/L?
Rationale- NaCl 3% is a hypertonic solution used to treat clients with hyponatremia. It should not be used in clients with hypernatremia. NaCl 0.45%, 5% dextrose and NaCl 0.25% are all hypotonic solutions that will help treat the hypernatremia.
Subcategory- Fluid and Electrolyte Imbalances
Rationale- NaCl 3% is a hypertonic solution used to treat clients with hyponatremia. It should not be used in clients with hypernatremia. NaCl 0.45%, 5% dextrose and NaCl 0.25% are all hypotonic solutions that will help treat the hypernatremia.
Subcategory- Fluid and Electrolyte Imbalances
A client presents to the emergency room with nausea, headache and altered mental status. The client completed a marathon two days prior and reports “drinking a lot of water to stay hydrated”. What imbalance does the nurse suspect?
Rationale- Nausea, headache and altered mental status are all signs of hyponatremia. Excessive water intake and sweating after activities such as marathons increase the risk of hyponatremia. The signs and symptoms and situation are not suggestive of hypokalemia, hyperglycemia or hypercalcemia.
Subcategory- Fluid and Electrolyte
Rationale- Nausea, headache and altered mental status are all signs of hyponatremia. Excessive water intake and sweating after activities such as marathons increase the risk of hyponatremia. The signs and symptoms and situation are not suggestive of hypokalemia, hyperglycemia or hypercalcemia.
Subcategory- Fluid and Electrolyte
The nurse is caring for a female client who has bruises on both wrists. The woman appears fearful when the spouse is in the room. What action by the nurse is priority?
Rationale – The nurse should ask the client about the bruises without the suspected abuser, spouse present. Once the nurse has spoken with the client then it may be indicated to contact the mandated reporter of line. Notifying the charge nurse is not priority. Documenting the bruising is important however not priority.
Subcategory – Abuse/Neglect (Psychosocial Integrity)
Rationale – The nurse should ask the client about the bruises without the suspected abuser, spouse present. Once the nurse has spoken with the client then it may be indicated to contact the mandated reporter of line. Notifying the charge nurse is not priority. Documenting the bruising is important however not priority.
Subcategory – Abuse/Neglect (Psychosocial Integrity)
The client is being seen for stress management. What type of coping mechanisms can be taught to the client to reduce stress? Select all that apply.
Rationale – Guided imagery and progressive muscle relaxation methods of relieving stress. Caffeine intake should be minimized or completely excluded, having the client only use caffeine before noon is not likely to reduce the stress. Exercising should be done at least 30 minutes, 60 minutes is not necessary every day. Using support groups such as family and friends is important in decreasing stress. It should be encouraged not discouraged.
Subcategory – Coping Mechanisms (Psychosocial Integrity)
Rationale – Guided imagery and progressive muscle relaxation methods of relieving stress. Caffeine intake should be minimized or completely excluded, having the client only use caffeine before noon is not likely to reduce the stress. Exercising should be done at least 30 minutes, 60 minutes is not necessary every day. Using support groups such as family and friends is important in decreasing stress. It should be encouraged not discouraged.
Subcategory – Coping Mechanisms (Psychosocial Integrity)
A teenage client is brought in by the ambulance after a witnessed seizure. The parents report that the child has recently had changes in behavior, difficulty sleeping and frequent absences from school. What diagnostic tests are priority in this client?
Rationale – The client is exhibiting multiple signs and symptoms of addictive behavior and substance abuse. A drug screen may reveal the causes of action of the seizure and other behavioral changes. A urine culture is not indicated. An echocardiogram may be indicated but is not priority. H&H levels are not likely to help in a diagnosis.
Subcategory – Chemical and other Dependencies/Substance Use Disorders (Psychosocial Integrity)
Rationale – The client is exhibiting multiple signs and symptoms of addictive behavior and substance abuse. A drug screen may reveal the causes of action of the seizure and other behavioral changes. A urine culture is not indicated. An echocardiogram may be indicated but is not priority. H&H levels are not likely to help in a diagnosis.
Subcategory – Chemical and other Dependencies/Substance Use Disorders (Psychosocial Integrity)
A client is admitted to the emergency department with A diagnosis of anxiety. The client reports a recent birth of their first child. The client is having difficulty adapting to their role as a parent and is feeling extreme guilt with their feelings. What type of crisis is the client experiencing?
Rationale – A maturational crisis is one that is provoked by transitions and life’s events. The birth of a child, parenthood and adolescents are other examples of maturational crises. Cultural crisis is one related to cultural assimilation. Situational crisis is an external event. An adventitious crisis is another term for a situational crisis.
Subcategory – Crisis Intervention (Psychosocial Integrity)
Rationale – A maturational crisis is one that is provoked by transitions and life’s events. The birth of a child, parenthood and adolescents are other examples of maturational crises. Cultural crisis is one related to cultural assimilation. Situational crisis is an external event. An adventitious crisis is another term for a situational crisis.
Subcategory – Crisis Intervention (Psychosocial Integrity)
The nurse is caring for a Russian child that has been brought to the emergency room with an anaphylactic reaction. What food should the nurse assess for relating to this culture?
Rationale –Honey is used in Russian culture for colds and coughs. It is believed that it has healing qualities. Shellfish, Dairy and peanuts are not foods used in this culture.
Subcategory – Cultural Awareness
Rationale –Honey is used in Russian culture for colds and coughs. It is believed that it has healing qualities. Shellfish, Dairy and peanuts are not foods used in this culture.
Subcategory – Cultural Awareness
A client admitted to the inpatient psychiatric unit with a diagnosis of borderline personality disorder tells the nurse “you were the only nurse that cares about me, none of the other nurses are nice to me.” What type of characteristic is the client demonstrating?
Rationale – Splitting is when a client individualizes their views and often rejects people or situations.
Subcategory – Mental Health Concepts
Rationale – Splitting is when a client individualizes their views and often rejects people or situations.
Subcategory – Mental Health Concepts
According to Chinese culture what food choices are neither cold nor hot? Select all that apply.
Rationale – Noodles and rice are not considered a hot or a cold food in Chinese culture. Chicken and eggs are both considered hot foods most vegetables are considered a cold food.
Subcategory – Cultural Awareness/Cultural Influences on Health
Rationale – Noodles and rice are not considered a hot or a cold food in Chinese culture. Chicken and eggs are both considered hot foods most vegetables are considered a cold food.
Subcategory – Cultural Awareness/Cultural Influences on Health
A Sikh female is being seen in the obstetrics unit for a preterm labor. What intervention is most appropriate in the care for this client?
Rationale – Sikh females tend to only want female caregivers. Especially in a female that is going to be giving birth. Allowing them time for prayer is important but not priority. There is no reason to speak directly to the husband. Informing the healthcare provider that they will not accept blood products is not indicated.
Subcategory – Cultural Awareness/Cultural Influences on Health
Rationale – Sikh females tend to only want female caregivers. Especially in a female that is going to be giving birth. Allowing them time for prayer is important but not priority. There is no reason to speak directly to the husband. Informing the healthcare provider that they will not accept blood products is not indicated.
Subcategory – Cultural Awareness/Cultural Influences on Health
What signs and symptoms are consistent with changes that occur in a decent hours before death? Select all that apply.
Rationale – In the days to hours before death, it is common for clients to be unresponsive and have difficulty or inability swallowing. They often have incontinence, not constipation. They will have decreased or no urine output. They will often have altered breathing patterns or apnea.
Subcategory – End of Life Care
Rationale – In the days to hours before death, it is common for clients to be unresponsive and have difficulty or inability swallowing. They often have incontinence, not constipation. They will have decreased or no urine output. They will often have altered breathing patterns or apnea.
Subcategory – End of Life Care
A client diagnosed with renal cancer is upset and arguing with his significant other. What type of defense mechanism is this client exhibiting?
Rationale – The client is displacing their anger towards their significant other. In denial they would not accept the fact that they are diagnosed with cancer. Regression they would act in a childlike manner. In rationalization they would attempt to justify the diagnosis.
Subcategory – Coping Mechanisms
Rationale – The client is displacing their anger towards their significant other. In denial they would not accept the fact that they are diagnosed with cancer. Regression they would act in a childlike manner. In rationalization they would attempt to justify the diagnosis.
Subcategory – Coping Mechanisms
A client recently diagnosed with stage for breast cancer with metastasis has been given a prognosis of 3 to 6 months to live. The client is crying and tells the nurse she “just needs to make amends with her son before she dies”. What stage of grieving is this client likely experiencing?
Rationale – During the bargaining phase of grieving the client often needs assistance with feelings such as guilt and fear and will discuss the need to finish things they have not accomplished. The statements do not exhibit denial, anger or depression.
Subcategory – Grief and Loss
Rationale – During the bargaining phase of grieving the client often needs assistance with feelings such as guilt and fear and will discuss the need to finish things they have not accomplished. The statements do not exhibit denial, anger or depression.
Subcategory – Grief and Loss
A seventh day Adventist client is admitted to the hospital with a diagnosis of acute appendicitis. What medication does the nurse recognize this client will not be able to receive related to the religious believes?
Rationale – Seventh-day Adventist clients are forbidden from taking opiate analgesics. They can take antibiotics, steroids, and blood products.
Subcategory – Religious and Spiritual Influences on Health
Rationale – Seventh-day Adventist clients are forbidden from taking opiate analgesics. They can take antibiotics, steroids, and blood products.
Subcategory – Religious and Spiritual Influences on Health
What statement regarding Amish customs and healthcare is accurate?
Rationale – Amish clients will need to seek permission from the church to seek care in the hospital. Amish patients can get transplantation of any organ except for the heart. They prefer the death occurs at home. They can receive any transfusion or blood products.
Subcategory – Cultural Awareness/Cultural Influences on Health
Rationale – Amish clients will need to seek permission from the church to seek care in the hospital. Amish patients can get transplantation of any organ except for the heart. They prefer the death occurs at home. They can receive any transfusion or blood products.
Subcategory – Cultural Awareness/Cultural Influences on Health
A client presents with delusions about religion and auditory hallucinations. What type of schizophrenia does the nurse suspect?
Rationale – Paranoid schizophrenia often presents with delusions about a particular thing and auditory hallucinations.
Subcategory- Mental health concepts
Rationale – Paranoid schizophrenia often presents with delusions about a particular thing and auditory hallucinations.
Subcategory- Mental health concepts
What is the priority of care for a client diagnosed with catatonic schizophrenia?
Rationale – Safety is the primary focus for a client with catatonic schizophrenia. Nutrition is important but not priority. Reorientation will likely not occur in acute phases of catatonic schizophrenia. A client with catatonic schizophrenia would not be able to participate in group therapy.
Subcategory- Mental health concepts
Rationale – Safety is the primary focus for a client with catatonic schizophrenia. Nutrition is important but not priority. Reorientation will likely not occur in acute phases of catatonic schizophrenia. A client with catatonic schizophrenia would not be able to participate in group therapy.
Subcategory- Mental health concepts
A client diagnosed with Alzheimer’s disease is agitated and pacing. The client asks “why is my roommate in my house?” What statement by the nurse is most therapeutic?
Rationale – It is important to reorient the client to the person and place. Giving the client information that is not accurate such as telling him that the person is there to visit for the day is not appropriate. Telling the client that the other client has been there longer is not therapeutic. Telling the client go for a walk it’s also not therapeutic.
Subcategory- Mental health concepts
Rationale – It is important to reorient the client to the person and place. Giving the client information that is not accurate such as telling him that the person is there to visit for the day is not appropriate. Telling the client that the other client has been there longer is not therapeutic. Telling the client go for a walk it’s also not therapeutic.
Subcategory- Mental health concepts
A client that is recently widowed is unable to express his feelings may be experiencing what?
Rationale – Dysfunctional grief may be when a person has difficulty expressing their feeling or may even deny them. Mourning is the act of the expression of grief. Maturational loss are predictable losses that occur in life, also known as situational losses. Anticipatory losses occur when one is caring for another that is terminal.
Subcategory – Grief and Loss
Rationale – Dysfunctional grief may be when a person has difficulty expressing their feeling or may even deny them. Mourning is the act of the expression of grief. Maturational loss are predictable losses that occur in life, also known as situational losses. Anticipatory losses occur when one is caring for another that is terminal.
Subcategory – Grief and Loss
The nurse is counseling the family of a client with end stage lung cancer about palliative care. The benefits and goals of palliative care can be identified at what? Select all that apply.
Rationale – Palliative care is designed to allow clients to enjoy comfort and the best possible quality of life when dealing with terminal illness. It is also designed to assist the families of the terminally ill to cope mentally and physically when meeting the demands of caring for a loved one. The timing of a death cannot be predicted merely by the presence of palliative care. It is important for health care professionals who work with clients at the end of life to examine their own personal beliefs and practices.
Subcategory – End of Life Care
Rationale – Palliative care is designed to allow clients to enjoy comfort and the best possible quality of life when dealing with terminal illness. It is also designed to assist the families of the terminally ill to cope mentally and physically when meeting the demands of caring for a loved one. The timing of a death cannot be predicted merely by the presence of palliative care. It is important for health care professionals who work with clients at the end of life to examine their own personal beliefs and practices.
Subcategory – End of Life Care
After dealing with an angry family member the nurse yells at a co-worker. What defense mechanism is being demonstrated?
Rationale – Displacement refers to the transfer of one’s emotional reactions onto another person or another object. Introjection is when one uses the values/beliefs of another as their own. Sublimation is when someone uses socially acceptable arenas to channel offensive behaviors such as aggression. Rationalization is when one attempts to justify socially inappropriate behaviors.
Subcategory – Coping Mechanisms
Rationale – Displacement refers to the transfer of one’s emotional reactions onto another person or another object. Introjection is when one uses the values/beliefs of another as their own. Sublimation is when someone uses socially acceptable arenas to channel offensive behaviors such as aggression. Rationalization is when one attempts to justify socially inappropriate behaviors.
Subcategory – Coping Mechanisms
A client states that she believe she is being punished by God during the final days of end stage colon cancer. What is the most appropriate action to take?
Rationale – Active listening allows clients the time to express their feelings without feeling judged. Offering personal beliefs religious or otherwise should be refrained from. Calling on a prayer group and the administration of anti-anxiety medication should be given at the client’s request.
Subcategory – End of Life Care
Rationale – Active listening allows clients the time to express their feelings without feeling judged. Offering personal beliefs religious or otherwise should be refrained from. Calling on a prayer group and the administration of anti-anxiety medication should be given at the client’s request.
Subcategory – End of Life Care
When performing a psychosocial assessment of a client what can be an indicator of depression?
Rationale – Unkempt appearance is an indicator of depression. Tense back muscles may be due to an injury or another diagnosis such as vertebral subluxation. The presence of anxiety does not assume the presence of depression. Tremors and weepiness are more likely a result of other diagnoses and are unlikely a sign of depression.
Subcategory – Mental Health Concepts
Rationale – Unkempt appearance is an indicator of depression. Tense back muscles may be due to an injury or another diagnosis such as vertebral subluxation. The presence of anxiety does not assume the presence of depression. Tremors and weepiness are more likely a result of other diagnoses and are unlikely a sign of depression.
Subcategory – Mental Health Concepts
In General Adaptation Syndrome what response to stress does the autonomic nervous system initiate?
Rationale – General Adaptation Syndrome is the body’s physiologic response to stress. The initial response from the autonomic nervous system is the fight or flight. An elevation in hormone levels prepares the body to either stay in defend against the stressor or to leave.
Subcategory – Stress Management
Rationale – General Adaptation Syndrome is the body’s physiologic response to stress. The initial response from the autonomic nervous system is the fight or flight. An elevation in hormone levels prepares the body to either stay in defend against the stressor or to leave.
Subcategory – Stress Management
What is the most important reason for explaining the steps of a procedure to a client prior to any treatment?
Rationale – Anticipatory guidance is when a member of the health care team informs a client about what to expect for an upcoming procedure or treatment. This allows for reduced anxiety a support for their coping mechanisms.
Subcategory – Stress Management
Rationale – Anticipatory guidance is when a member of the health care team informs a client about what to expect for an upcoming procedure or treatment. This allows for reduced anxiety a support for their coping mechanisms.
Subcategory – Stress Management
A client is admitted to the hospital with chest pain. The client reports their heart is beating very fast. What action by the nurse is priority?
Rationale – The client reports her heart is beating very fast the nurse must determine the rate of the heartbeat. A rapid heart rate is not an indication for a rapid response. If the client’s rate is very rapid the nurse should then contact the health care provider. A complete cardiac assessment should not be done until the rate is determined in the provider has been contacted.
Subcategory- Changes in vital signs
Rationale – The client reports her heart is beating very fast the nurse must determine the rate of the heartbeat. A rapid heart rate is not an indication for a rapid response. If the client’s rate is very rapid the nurse should then contact the health care provider. A complete cardiac assessment should not be done until the rate is determined in the provider has been contacted.
Subcategory- Changes in vital signs
What diagnostic test is ordered to confirm a diagnosis if a client tested positive for HIV using the enzyme immunoassay (EIA) test?
Rationale – Western blot test is diagnostic for HIV test. Chest x-ray will not be diagnostics for HIV. Viral load testing is not used for diagnosis. They will not repeat a test if it was already positive. It is used when a client has a positive EIA.
Subcategory- Laboratory tests
Rationale – Western blot test is diagnostic for HIV test. Chest x-ray will not be diagnostics for HIV. Viral load testing is not used for diagnosis. They will not repeat a test if it was already positive. It is used when a client has a positive EIA.
Subcategory- Laboratory tests
A 39 year-old woman presents to the prenatal clinic for a nuchal translucency (NT) test. She has a BMI of 42, and her blood type is O negative. For which of the following conditions does the NT test screen?
Rationale – NT test screens for Down syndrome. An increased nuchal fold is a marker for DS.
Subcategory – Laboratory Test
Rationale – NT test screens for Down syndrome. An increased nuchal fold is a marker for DS.
Subcategory – Laboratory Test
The nurse is evaluating the fetal heart rate and uterine contraction tracing. Which of the following findings would prompt further assessment?
Rationale – Fetal heart rate variability of 6-25 beats represents fetal tachycardia and patient should be re-positioned and vital signs obtained. Other choices are normal/expected findings.
Subcategory- Diagnostic Tests
Rationale – Fetal heart rate variability of 6-25 beats represents fetal tachycardia and patient should be re-positioned and vital signs obtained. Other choices are normal/expected findings.
Subcategory- Diagnostic Tests
The nurse is evaluating the fetal heart tracing and notes two abrupt fluctuations in the baseline fetal heart rate 15 beats per minute above baseline, lasting 15 seconds each, with return to baseline. Which of the following is the correct term for this finding?
Rationale – Acceleration as per NICHD guidelines.
Subcategory- Diagnostic Tests
Rationale – Acceleration as per NICHD guidelines.
Subcategory- Diagnostic Tests
Prior to a client having an inpatient diagnostic MRI procedure without contrast, which of the following is a priority question that the nurse in radiology must ask?
Rationale– MRI is contraindicated in clients with implanted devices. Ear protection is not a priority. The procedure does not require contrast making food allergy assessment unnecessary. Pain medications would not be given in radiology. Pain should be addressed prior to the procedure.
Subcategory- Diagnostic Tests
Rationale– MRI is contraindicated in clients with implanted devices. Ear protection is not a priority. The procedure does not require contrast making food allergy assessment unnecessary. Pain medications would not be given in radiology. Pain should be addressed prior to the procedure.
Subcategory- Diagnostic Tests
What finding should be reported immediately in a client that has a lumbar puncture ordered?
Rationale – A client with an increase in a cranial pressure or infection at the site of puncture should not have a lumbar puncture performed. Headaches are often the reason a client has a lumbar puncture. Elevated potassium levels will not affect a lumbar puncture. A recent urinary tract infection does not contraindicate an LP.
Subcategory – Diagnostic Test
Rationale – A client with an increase in a cranial pressure or infection at the site of puncture should not have a lumbar puncture performed. Headaches are often the reason a client has a lumbar puncture. Elevated potassium levels will not affect a lumbar puncture. A recent urinary tract infection does not contraindicate an LP.
Subcategory – Diagnostic Test
What procedure involves a catheter insertion in the femoral artery that is passed to the aortic arch and into the carotid or vertebral artery for injection of contrast to locate or identify abscesses aneurysms are hematomas?
Rationale – Cerebral angiography involves the catheter being passed to the crowded artery for the injection of contrast and location of abscesses, aneurysms or hematomas. A Myelogram is an x-ray after contrast medium is injected. CT scans do not involve catheter insertion. And EEG does not involve catheter insertion.
Subcategory – Diagnostic Test
Rationale – Cerebral angiography involves the catheter being passed to the crowded artery for the injection of contrast and location of abscesses, aneurysms or hematomas. A Myelogram is an x-ray after contrast medium is injected. CT scans do not involve catheter insertion. And EEG does not involve catheter insertion.
Subcategory – Diagnostic Test
A client is suspected of having benign prostatic hyperplasia. What diagnostic tests does the nurse anticipate being completed? Select all that apply.
Rationale – A digital rectal exam, Transrectal ultrasound in a cystoscopy may be used to diagnose BPH. An MRI is not used in diagnosis. An open prostatectomy is used to treat not diagnosed.
Subcategory – Diagnostic Test
Rationale – A digital rectal exam, Transrectal ultrasound in a cystoscopy may be used to diagnose BPH. An MRI is not used in diagnosis. An open prostatectomy is used to treat not diagnosed.
Subcategory – Diagnostic Test
What diagnostic test is recommended for a woman who is high risk for breast cancer?
Rationale – An MRI is recommended as a sensitive screening tool for women who are at high risk for breast cancer. Biopsy is not indicated at the mass is not located. Ultrasound is not as diagnostic as mammography or MRI. A mammography may also be used but is not recommended for clients that are at high risk for breast cancer.
Subcategory – Diagnostic Test
Rationale – An MRI is recommended as a sensitive screening tool for women who are at high risk for breast cancer. Biopsy is not indicated at the mass is not located. Ultrasound is not as diagnostic as mammography or MRI. A mammography may also be used but is not recommended for clients that are at high risk for breast cancer.
Subcategory – Diagnostic Test
A client is being tested for diagnosis of Cushing’s syndrome. What diagnostic study does the nurse anticipate?
Rationale – A 24 hour collection for free cortisol is diagnostic test used for Cushing’s syndrome. The serum TSH levels are used to diagnose thyroid disorders. An ACTH stimulation test is used to diagnose Addison’s. The serum anti-parathyroid antibody is used for hypoparathyroidism.
Subcategory – Diagnostic Test
Rationale – A 24 hour collection for free cortisol is diagnostic test used for Cushing’s syndrome. The serum TSH levels are used to diagnose thyroid disorders. An ACTH stimulation test is used to diagnose Addison’s. The serum anti-parathyroid antibody is used for hypoparathyroidism.
Subcategory – Diagnostic Test
Which test will identify microscopic amounts of blood in feces?
Rationale – A fecal occult blood test is the way of determining microscopic amounts of blood in feces. All other tests are used to look at the structure of the G.I. tract.
Subcategory –Diagnostic Test
Rationale – A fecal occult blood test is the way of determining microscopic amounts of blood in feces. All other tests are used to look at the structure of the G.I. tract.
Subcategory –Diagnostic Test
The nurse has received a urinalysis report. What finding should be reported to the health care provider immediately?
Rationale – Protein in the urine is significant for renal complications and should be reported to the health care provider immediately. A pH of 7.0 is normal for specific gravity is normal and scant white blood cells is not priority and does not need to be reported immediately.
Subcategory – Laboratory Test
Rationale – Protein in the urine is significant for renal complications and should be reported to the health care provider immediately. A pH of 7.0 is normal for specific gravity is normal and scant white blood cells is not priority and does not need to be reported immediately.
Subcategory – Laboratory Test
The client scheduled for intermittent urinary catheterization has an order for the nurse to check the volume of urine in the bladder prior to catheterization. What diagnostic test does the nurse utilize for this measurement?
Rationale – A bladder ultrasound is used to identify the volume of urine in the bladder prior to intermittent catheterization. A CT scan, abdominal x-ray and urodynamic testing are not used to determine urine in the bladder prior to catheterization.
Subcategory – Diagnostic Testing
Rationale – A bladder ultrasound is used to identify the volume of urine in the bladder prior to intermittent catheterization. A CT scan, abdominal x-ray and urodynamic testing are not used to determine urine in the bladder prior to catheterization.
Subcategory – Diagnostic Testing
What intervention is priority prior to accessing a dialysis fistula?
Rationale – The nurse should always assess for a bruit and thrill prior to accessing a hemodialysis fistula. Holding medications is not indicated with all medications and not priority. Checking INR level is not priority. Determining where last access was is not priority.
Subcategory – Potential for complications of Treatments
Rationale – The nurse should always assess for a bruit and thrill prior to accessing a hemodialysis fistula. Holding medications is not indicated with all medications and not priority. Checking INR level is not priority. Determining where last access was is not priority.
Subcategory – Potential for complications of Treatments
A nurse is performing an exchange on a client that is undergoing peritoneal dialysis. The peritoneal effluent is cloudy and the client is reporting mild abdominal pain. What action by the nurse is priority?
Rationale – A client with cloudy effluent during peritoneal dialysis with pain likely is experiencing peritonitis and the fluid should be cultured immediately. Vital signs should be taken after a sample has been obtained. This is not a normal finding. The fluid should never be returned to the peritoneal cavity.
Subcategory – Diagnostic Tests
Rationale – A client with cloudy effluent during peritoneal dialysis with pain likely is experiencing peritonitis and the fluid should be cultured immediately. Vital signs should be taken after a sample has been obtained. This is not a normal finding. The fluid should never be returned to the peritoneal cavity.
Subcategory – Diagnostic Tests
The nurse asked the client to raise her arms in front of them with the palms facing upward. The client left arm drift downward. What does this indicate to the nurse?
Rationale – A client with a left arm drifting likely has weakness in that arm. Concentration would not result in Palmer drift. Cranial nerve three controls the eye not the arm. A cerebrovascular accident may cause weakness, however a left sided CVA would result in right sided weakness.
Subcategory – System Specific Assessment
Rationale – A client with a left arm drifting likely has weakness in that arm. Concentration would not result in Palmer drift. Cranial nerve three controls the eye not the arm. A cerebrovascular accident may cause weakness, however a left sided CVA would result in right sided weakness.
Subcategory – System Specific Assessment
A client that has a spinal cord injury develops a headache, diaphoresis and of hypertension and bradycardia. What intervention by the nurse is priority?
Rationale – The client has signs of autonomic dysreflexia which is most often caused by bladder distention and constipation. The first thing the nurse is to do is assess for bladder distention and catheterize the client if necessary. Relieving the cause is the only way to resolve autonomic dysreflexia. After the client is assessed for bladder distention and constipation, and is unable to determine the cause or has determined the cause, the healthcare provider should be contacted. Oxygen will not resolve autonomic dysreflexia. Continuous ECG monitoring may be necessary but not priority.
Subcategory – Potential for Complications/Health Alterations
Rationale – The client has signs of autonomic dysreflexia which is most often caused by bladder distention and constipation. The first thing the nurse is to do is assess for bladder distention and catheterize the client if necessary. Relieving the cause is the only way to resolve autonomic dysreflexia. After the client is assessed for bladder distention and constipation, and is unable to determine the cause or has determined the cause, the healthcare provider should be contacted. Oxygen will not resolve autonomic dysreflexia. Continuous ECG monitoring may be necessary but not priority.
Subcategory – Potential for Complications/Health Alterations
What intervention can be performed to decrease the risk of infection at the insertion site of a central venous catheter?
Rationale – A chlorhexidine impregnated patch is often place at the insertion site and decreases the risk of infection at the site. Flushing the port every shift maintain patency but does not decrease risk of infection at the insertion site. The dressing should not be changed every day. Scrubbing the hub with alcohol after chlorhexidine is not indicated nor will it decrease the risk of infection at the insertion site.
Subcategory – Potential for Complications
Rationale – A chlorhexidine impregnated patch is often place at the insertion site and decreases the risk of infection at the site. Flushing the port every shift maintain patency but does not decrease risk of infection at the insertion site. The dressing should not be changed every day. Scrubbing the hub with alcohol after chlorhexidine is not indicated nor will it decrease the risk of infection at the insertion site.
Subcategory – Potential for Complications
The nurse is performing an abdominal assessment. The client asked the nurse what the purposes of listening before they feel the abdomen. What statement by the nurse demonstrates a correct understanding of the rationale?
Rationale – By palpitating before auscultating the nurse will not accurately hear the bowel sounds. Pressing on the abdomen is not more invasive. Even if an abnormality is heard the nurse may still palpate the abdomen. The length of time it takes to listen does not affect the outcome of our rationale for the sequence.
Subcategory – System Specific Assessments
Rationale – By palpitating before auscultating the nurse will not accurately hear the bowel sounds. Pressing on the abdomen is not more invasive. Even if an abnormality is heard the nurse may still palpate the abdomen. The length of time it takes to listen does not affect the outcome of our rationale for the sequence.
Subcategory – System Specific Assessments
The nurse is assessing the BMI for a client that is being admitted to their unit. The clients BMI is 34. What category with this client be classified?
Rationale – A client with a BMI over 30 is considered to be obese.
Subcategory – System Specific Assessments
Rationale – A client with a BMI over 30 is considered to be obese.
Subcategory – System Specific Assessments
What signs and symptoms would be detected on the assessment of a client with an inadequate nutrition? Select all that apply.
Rationale – Dry dull hair and dry patches on the skin are signs of malnutrition. General weakness is another sign of malnutrition. The blood pressure is normal and would not be an indication of malnutrition. Subcutaneous fat would be decreased, not increased.
Subcategory – System Specific Assessments
Rationale – Dry dull hair and dry patches on the skin are signs of malnutrition. General weakness is another sign of malnutrition. The blood pressure is normal and would not be an indication of malnutrition. Subcutaneous fat would be decreased, not increased.
Subcategory – System Specific Assessments
The nurse is caring for a client with a chest tube. What finding should be reported to the health care provider immediately?
Rationale – Continuous bubbling in the water seal chamber indicates there is an air leak and must be reported immediately. There’s nothing wrong with 50 ML’s out in eight hours. There is usually a gentle bubbling in the suction control chamber. It is normal to have fluctuations in the water seal chamber with respirations.
Subcategory – Potential for Complications of Treatments
Rationale – Continuous bubbling in the water seal chamber indicates there is an air leak and must be reported immediately. There’s nothing wrong with 50 ML’s out in eight hours. There is usually a gentle bubbling in the suction control chamber. It is normal to have fluctuations in the water seal chamber with respirations.
Subcategory – Potential for Complications of Treatments
What action by the nurse is priority in a diabetic client is scheduled for an IV pyelogram?
Rationale – Metformin should be held for a minimum of 48 hours prior to the procedure because it can cause life-threatening lactic acidosis. An IV should be inserted but only after it has been assured that there is no allergies to shellfish or iodine and that the client has not taking this medication. A bowel prep is often ordered the night before.
Subcategory – Potential for Complications of Diagnostic Tests
Rationale – Metformin should be held for a minimum of 48 hours prior to the procedure because it can cause life-threatening lactic acidosis. An IV should be inserted but only after it has been assured that there is no allergies to shellfish or iodine and that the client has not taking this medication. A bowel prep is often ordered the night before.
Subcategory – Potential for Complications of Diagnostic Tests
A client suspected of having myasthenia gravis has undergone administration of IV edrophonium chloride. What finding indicates a positive diagnosis?
Rationale – When a client is administered Tensilon they will improve for a period of time and gradually as the Tensilon wears off the client will have weakness return. The improvement of symptoms is an indicator that the client has myasthenia gravis.
Subcategory – Diagnostic Tests
Rationale – When a client is administered Tensilon they will improve for a period of time and gradually as the Tensilon wears off the client will have weakness return. The improvement of symptoms is an indicator that the client has myasthenia gravis.
Subcategory – Diagnostic Tests
A client diagnosed with Guillain-Barre syndrome has had paralysis that his extended to the top of the head. The client has impaired extraocular movements and has just been intubated. What additional action by the nurse is priority? Select all that apply.
Rationale – Utilizing artificial tears, taping the client’s eyes shut and using eye shields promotes health in a client who has progressive GBS. If the client process has advanced to the top of their head they are not going to be able to move their eyes back-and-forth or open and close their eyes on their own.
Subcategory – Potential for Alterations in Body Systems
Rationale – Utilizing artificial tears, taping the client’s eyes shut and using eye shields promotes health in a client who has progressive GBS. If the client process has advanced to the top of their head they are not going to be able to move their eyes back-and-forth or open and close their eyes on their own.
Subcategory – Potential for Alterations in Body Systems
A client with intracranial pressure monitoring has clear drainage around the monitor site. What action by the nurse is priority?
Rationale – Clear drainage around and intracranial pressure monitoring device is an indication of cerebrospinal fluid leakage. This should be reported to the health care provider immediately. Documenting the finding should be done after the provider is notified. Repositioning the monitor should not be done. The fluid not touching the monitor is not a priority.
Subcategory – Potential for Complications of Procedures
Rationale – Clear drainage around and intracranial pressure monitoring device is an indication of cerebrospinal fluid leakage. This should be reported to the health care provider immediately. Documenting the finding should be done after the provider is notified. Repositioning the monitor should not be done. The fluid not touching the monitor is not a priority.
Subcategory – Potential for Complications of Procedures
A nurse is providing teaching to a newly pregnant teenager regarding teratogens. What statement by the client indicates a need for further teaching?
Rationale – Infection, whether treated early or not, can interfere with fetal development. Alcohol may lead to fetal alcohol syndrome. Tobacco use can lead to preterm labor. If a client is having an x-ray they should notify the physician that they are pregnant.
Subcategory – Potential for Alterations in Body Systems
Rationale – Infection, whether treated early or not, can interfere with fetal development. Alcohol may lead to fetal alcohol syndrome. Tobacco use can lead to preterm labor. If a client is having an x-ray they should notify the physician that they are pregnant.
Subcategory – Potential for Alterations in Body Systems
A client that has undergone a transurethral resection of the prostate is receiving continuous bladder irrigation. The nurse notes clots in the catheter drainage bag. What action by the nurse is most appropriate?
Rationale – Clots found in the bag from continuous bladder irrigation are an indication that the fluid may need to be increased. Most orders will allow the nurse to increase it to reduce the output of clotting. Changing the catheter bag is contraindicated. Turning off the bladder irrigation will only increase clotting and cause complications. The healthcare provider does not need to be contacted and less the clotting does not stop.
Subcategory – Potential for Alterations in Body Systems
Rationale – Clots found in the bag from continuous bladder irrigation are an indication that the fluid may need to be increased. Most orders will allow the nurse to increase it to reduce the output of clotting. Changing the catheter bag is contraindicated. Turning off the bladder irrigation will only increase clotting and cause complications. The healthcare provider does not need to be contacted and less the clotting does not stop.
Subcategory – Potential for Alterations in Body Systems
What test with the nurse expect to be positive in a client diagnosed with an anterior cruciate ligament tear?
Rationale –Lachman’s Test is a positive finding a client with an ACL tear. Drop arm test, Phalen’s sign in Allen’s test you’re not indicative of an ACL knee injury.
Subcategory – System Specific Assessments
Rationale –Lachman’s Test is a positive finding a client with an ACL tear. Drop arm test, Phalen’s sign in Allen’s test you’re not indicative of an ACL knee injury.
Subcategory – System Specific Assessments
What treatment is used to remove IgG antibodies in a client diagnosed with myasthenia gravis?
Rationale – Plasmapheresis is used to remove IgG antibodies from a client diagnosed with myasthenia gravis. Immunosuppressants, Anti-cholinesterase and Thymectomy will not be used to decrease the IgG levels.
Subcategory – Therapeutic Procedures
Rationale – Plasmapheresis is used to remove IgG antibodies from a client diagnosed with myasthenia gravis. Immunosuppressants, Anti-cholinesterase and Thymectomy will not be used to decrease the IgG levels.
Subcategory – Therapeutic Procedures
After administration of succimer to a client diagnosed with lead poisoning, what lab values are priority to assess? Select all that apply.
Rationale –Neutrophils and Bilirubin can be elevated, this medication will often cause liver function abnormalities and neutropenia. Calcium, potassium and hematocrit are not affected by this form of chelation.
Subcategory – Laboratory Values
Rationale –Neutrophils and Bilirubin can be elevated, this medication will often cause liver function abnormalities and neutropenia. Calcium, potassium and hematocrit are not affected by this form of chelation.
Subcategory – Laboratory Values
A client that returned from a bronchoscopy two hours ago is requesting water. What action by the nurse is most appropriate?
Rationale – It is important to assess for a gag reflex before allowing a client to have food or fluids after a bronchoscopy. Ice chips should not be given as a gag reflex has not returned. It is not necessary to consult the doctor. There’s no need to tell the client that they have to wait another two hours.
Subcategory – Potential for Complications from Diagnostic Tests
Rationale – It is important to assess for a gag reflex before allowing a client to have food or fluids after a bronchoscopy. Ice chips should not be given as a gag reflex has not returned. It is not necessary to consult the doctor. There’s no need to tell the client that they have to wait another two hours.
Subcategory – Potential for Complications from Diagnostic Tests
The nurse is caring for a client who is undergone a below the knee amputation. What action by the nurse demonstrates a need for further teaching?
Rationale – The residual limb should not be placed on a pillow as it increases the risk for flexion contracture of the hip. Applying an elastic wrap to the residual limb is indicated. Opiate analgesics have shown to decrease phantom limb pain. It is good to encourage the client to look and feel the residual limb.
Subcategory – Potential for Complications from Surgical Procedures
Rationale – The residual limb should not be placed on a pillow as it increases the risk for flexion contracture of the hip. Applying an elastic wrap to the residual limb is indicated. Opiate analgesics have shown to decrease phantom limb pain. It is good to encourage the client to look and feel the residual limb.
Subcategory – Potential for Complications from Surgical Procedures
The nurse receives an order for a bone scan on a client suspected of having osteomyelitis. What finding should be reported to the health care provider immediately?
Rationale – The priority information that should be reported to the health care provider immediately is an allergy to iodine as this may contraindicate the test. The blood pressure is elevated but does not preclude the client from having the test. The white blood cell count would be consistent with a diagnosis of osteomyelitis. COPD does not come to indicate this test.
Subcategory – Potential for Complications of Diagnostic Tests
Rationale – The priority information that should be reported to the health care provider immediately is an allergy to iodine as this may contraindicate the test. The blood pressure is elevated but does not preclude the client from having the test. The white blood cell count would be consistent with a diagnosis of osteomyelitis. COPD does not come to indicate this test.
Subcategory – Potential for Complications of Diagnostic Tests
A hospital employee arrives in the emergency department with sudden onset of wheezing, dizziness and hives of upper extremities. It is a priority for the nurse in the emergency department to determine which of the following? Select all that apply.
Rationale – Health care workers are at high risk for developing latex sensitivity, these are signs and symptoms of anaphylaxis. Latex allergy could be a cause for the presenting signs and symptoms. Prior medical history would include allergies and medications, possible causes for anaphylactic symptoms. Location of home and time of last meal are of no significance to this scenario. Departments such as nursing, medicine, and housekeeping are at higher risk of anaphylaxis related to repeated exposure to latex products but this information is not a priority.
Subcategory- Accident/Injury Prevention
Rationale – Health care workers are at high risk for developing latex sensitivity, these are signs and symptoms of anaphylaxis. Latex allergy could be a cause for the presenting signs and symptoms. Prior medical history would include allergies and medications, possible causes for anaphylactic symptoms. Location of home and time of last meal are of no significance to this scenario. Departments such as nursing, medicine, and housekeeping are at higher risk of anaphylaxis related to repeated exposure to latex products but this information is not a priority.
Subcategory- Accident/Injury Prevention
The nurse has just completed teaching a postpartum client about infant car seats. Which statement by the client indicates they need further teaching?
Rationale – A mirror on front dash to see infant’s face would mean the infant is in a car seat that is front-facing. Infant car seats should be rear-facing in the back seat. A car seat that meets federal guidelines, an appropriately sized car seat, and a five-point harness with broad straps and head shield are proper guidelines.
Subcategory- Accident/Injury Prevention
Rationale – A mirror on front dash to see infant’s face would mean the infant is in a car seat that is front-facing. Infant car seats should be rear-facing in the back seat. A car seat that meets federal guidelines, an appropriately sized car seat, and a five-point harness with broad straps and head shield are proper guidelines.
Subcategory- Accident/Injury Prevention
A hospital has been alerted to a community disaster with large numbers of injured being transported to the Emergency Department. As the triage nurse, which of the following clients, with the injuries described below, would receive a red tag priority. Select all that apply.
Rationale – In the widely used North American Treaty Organization (NATO) triage system, level 1 priority clients are given a red tag priority –those seen first. Chest injury with obstructed airway in full cardiac arrest and an unresponsive patient with multiple open head wounds and fixed/dilated pupils are black tag, level 4 priorities with survival unlikely even with interventions. Multiple abrasions of bilateral buttocks with symptomatic panic attack is a green tag, level 3 priority.
Subcategory- Emergency Response Plans
Rationale – In the widely used North American Treaty Organization (NATO) triage system, level 1 priority clients are given a red tag priority –those seen first. Chest injury with obstructed airway in full cardiac arrest and an unresponsive patient with multiple open head wounds and fixed/dilated pupils are black tag, level 4 priorities with survival unlikely even with interventions. Multiple abrasions of bilateral buttocks with symptomatic panic attack is a green tag, level 3 priority.
Subcategory- Emergency Response Plans
The nurse is implementing teaching with the parent of a three year-old who will be returning home, confined there, with continuous oxygen therapy provided by an oxygen concentrator. Which statement by the client indicates that teaching has been successful?
Rationale – Emergency plans must be in place if the power is interrupted. Understanding that you must shut the oxygen off for a cigarette break demonstrates the parent lacks understanding of the need for oxygen 24 hours a day, the dangers of second hand smoke to the child who already has compromised lung function, and the fire hazard of combustibility of bedding and clothing saturated with oxygen though the oxygen source is shut off. An oxygen concentrator’s humidification cylinder should be cleaned weekly. Wind-up toys present a spark/fire hazard.
Subcategory- Accident/Injury Prevention
Rationale – Emergency plans must be in place if the power is interrupted. Understanding that you must shut the oxygen off for a cigarette break demonstrates the parent lacks understanding of the need for oxygen 24 hours a day, the dangers of second hand smoke to the child who already has compromised lung function, and the fire hazard of combustibility of bedding and clothing saturated with oxygen though the oxygen source is shut off. An oxygen concentrator’s humidification cylinder should be cleaned weekly. Wind-up toys present a spark/fire hazard.
Subcategory- Accident/Injury Prevention
The Emergency Department staff is preparing for a large number of injured following an earthquake. Which of the following client conditions would be the most emergent concern for the nurse?
Rationale – Pulmonary function can be compromised by crushed chest, inhalation of debris, hazardous chemicals or flames. Chest pain may indicate acute cardiac syndrome, panic, or soft tissue injury. In the event of acute cardiac syndrome –this would be a secondary priority to pulmonary compromise. Closed and open head injuries are not priorities if client is stable. Victims with rapidly declining neurological status are not a priority in mass casualty disasters since survival rate is extremely poor. Resources will be directed to the victims that have a greater survival probability. Though dehydration can pose life-threatening consequences, interventions for rescue of clients with dehydration can be postponed to intervene with pulmonary and cardiac compromise.
Subcategory- Emergency Response Plan
Rationale – Pulmonary function can be compromised by crushed chest, inhalation of debris, hazardous chemicals or flames. Chest pain may indicate acute cardiac syndrome, panic, or soft tissue injury. In the event of acute cardiac syndrome –this would be a secondary priority to pulmonary compromise. Closed and open head injuries are not priorities if client is stable. Victims with rapidly declining neurological status are not a priority in mass casualty disasters since survival rate is extremely poor. Resources will be directed to the victims that have a greater survival probability. Though dehydration can pose life-threatening consequences, interventions for rescue of clients with dehydration can be postponed to intervene with pulmonary and cardiac compromise.
Subcategory- Emergency Response Plan
An active client diagnosed with rheumatoid arthritis is asking about assistive devices that may help them with their activities of daily living. What assistive device would be most helpful for this client?
Rationale – Deformity of the hands and feet are common in rheumatoid arthritis and adaptive utensils can help the client eat with less discomfort of the hands. A wheelchair is unnecessary at this time and would put client at risk for the complications of immobility. A slide board is equipment that is reserved for a client who cannot bear weight to transfer. Since grasping is a challenge for clients with rheumatoid arthritis, a grabbing device requiring a good grasp for use would not be appropriate.
Subcategory- Ergonomic Principles
Rationale – Deformity of the hands and feet are common in rheumatoid arthritis and adaptive utensils can help the client eat with less discomfort of the hands. A wheelchair is unnecessary at this time and would put client at risk for the complications of immobility. A slide board is equipment that is reserved for a client who cannot bear weight to transfer. Since grasping is a challenge for clients with rheumatoid arthritis, a grabbing device requiring a good grasp for use would not be appropriate.
Subcategory- Ergonomic Principles
The nurse observes a UAP starting to transfer a client out of bed using unsafe techniques. Which is the most appropriate action for the nurse to take next?
Rationale – The nurse retains accountability for client safety and must intervene immediately. This also gives the nurse an opportunity to reinforce safe transfer techniques during the transfer. Immediately scheduling the UAP to complete a safe transfer does not assure the client’s immediate safety if the UAP continues the transfer. The nurse is accountable for the competency of the UAP and should intervene immediately when client safety is compromised. Telling the UAP they are not safe and to leave the room is punitive and embarrassing for the UAP and could instill doubt of staff competency in the client.
Subcategory- Ergonomic Principles
Rationale – The nurse retains accountability for client safety and must intervene immediately. This also gives the nurse an opportunity to reinforce safe transfer techniques during the transfer. Immediately scheduling the UAP to complete a safe transfer does not assure the client’s immediate safety if the UAP continues the transfer. The nurse is accountable for the competency of the UAP and should intervene immediately when client safety is compromised. Telling the UAP they are not safe and to leave the room is punitive and embarrassing for the UAP and could instill doubt of staff competency in the client.
Subcategory- Ergonomic Principles
The nurse has experienced a needle stick after drawing blood from a client with Hepatitis C. What is the first action the nurse should take?
Rationale – Decreasing time exposure to potentially contaminated blood is appropriate. Filling out an injury/accident report, notifying the acting nurse supervisor, and immediately reporting to health services are steps taken after cleaning wound.
Subcategory- Handling Hazardous and Infectious Material
Rationale – Decreasing time exposure to potentially contaminated blood is appropriate. Filling out an injury/accident report, notifying the acting nurse supervisor, and immediately reporting to health services are steps taken after cleaning wound.
Subcategory- Handling Hazardous and Infectious Material
The nurse observes a client using their walker for ambulation. Which action be the client requires further safety teaching with the client?
Rationale – It is unsafe the pull on the walker to get out of a chair –it can be pulled over and the client can fall. Placing hand on arms of the chair before sitting, using the walker for stability when getting out of bed, and placing the walker slightly in front of the patient are all safe walker use.
Subcategory- Safe Use of Equipment
Rationale – It is unsafe the pull on the walker to get out of a chair –it can be pulled over and the client can fall. Placing hand on arms of the chair before sitting, using the walker for stability when getting out of bed, and placing the walker slightly in front of the patient are all safe walker use.
Subcategory- Safe Use of Equipment
In preparing an emergency response plan for a hospital, the nurse recognizes the priority as;
Rationale – Using critical thinking to develop a response plan occurs in the planning phase. Identifying the nursing roles in the disaster plan is part of the planning phase but use of decision-making/critical thinking to develop plan takes priority over this. Participating in the disaster planning and determining patient client transfers are implementation phase of plan.
Subcategory- Emergency Response Plans
Rationale – Using critical thinking to develop a response plan occurs in the planning phase. Identifying the nursing roles in the disaster plan is part of the planning phase but use of decision-making/critical thinking to develop plan takes priority over this. Participating in the disaster planning and determining patient client transfers are implementation phase of plan.
Subcategory- Emergency Response Plans
The nurse is reviewing the critical pathway for a client who had abdominal surgery two days ago. The pathway state that on two the client will achieve 100% of volume goal on the incentive spirometer. The client has achieved 40% of volume goal on the incentive spirometer. Which choice below, accurately describes this finding?
Rationale – This is a goal that is not met, a variance from the expected outcome on the critical pathway. An incident is a mishap affecting a client in the hospital. An unforeseen occurrence usually involving injury is an accident. A sentinel event involves death, serious physiological or psychological consequences such as wrong site surgery.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
Rationale – This is a goal that is not met, a variance from the expected outcome on the critical pathway. An incident is a mishap affecting a client in the hospital. An unforeseen occurrence usually involving injury is an accident. A sentinel event involves death, serious physiological or psychological consequences such as wrong site surgery.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
The nurse recognizes which of the following to be a sentinel event?
Rationale – A sentinel event is an event resulting in death, serious physiological or psychological harm. A client with MRSA roomed with one without, IV fluid infusion that gets infiltrated, and a client who fails to achieve critical pathway goals by date do not meet the criteria of a sentinel event.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
Rationale – A sentinel event is an event resulting in death, serious physiological or psychological harm. A client with MRSA roomed with one without, IV fluid infusion that gets infiltrated, and a client who fails to achieve critical pathway goals by date do not meet the criteria of a sentinel event.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
The nurse recognizes that administering antibiotics to a client with an active infection is breaking the chain of infection at which link?
Rationale – The antibiotic is to kill the causative agent and stop it from replicating. A reservoir would be the location of the infection where the etiological agent has multiplied. Mode of exit is the means that the etiological agent finds to exit the host. Interventions such as proper nutrition, fluid and rest are actions to strengthen a person so they are better able to physiologically fight an invading organism.
Subcategory- Standard Precautions/Transmission-based Precautions/Surgical Asepsis
Rationale – The antibiotic is to kill the causative agent and stop it from replicating. A reservoir would be the location of the infection where the etiological agent has multiplied. Mode of exit is the means that the etiological agent finds to exit the host. Interventions such as proper nutrition, fluid and rest are actions to strengthen a person so they are better able to physiologically fight an invading organism.
Subcategory- Standard Precautions/Transmission-based Precautions/Surgical Asepsis
Which link in the chain of infection is interrupted by the actions of the nurse changing a client’s linens?
Rationale – Soiled linens act as a vehicle to transport the etiologic agent or mode of transmission. Etiologic agents would be actions such as administering antibiotics and sanitation of surgical instruments. Means of entry indicates an entry into a host i.e. broken skin. Susceptible hosts would be actions such as encouraging proper nutrition, fluids, and rest.
Subcategory- Standard Precautions/Transmission-based Precautions/Surgical Asepsis
Rationale – Soiled linens act as a vehicle to transport the etiologic agent or mode of transmission. Etiologic agents would be actions such as administering antibiotics and sanitation of surgical instruments. Means of entry indicates an entry into a host i.e. broken skin. Susceptible hosts would be actions such as encouraging proper nutrition, fluids, and rest.
Subcategory- Standard Precautions/Transmission-based Precautions/Surgical Asepsis
The nurse has established a goal for a client with an infected draining wound that reads, “Client’s wound will begin healing as demonstrated by absence of signs/symptoms of infection, decreasing wound size, and decreasing exudate within one week. The nurse plans to evaluate goal attainment by which of the following?
Rationale – The goal was that wound would heal. Assessing the wound is the only option for determining healing. Asking the client if they have adhered to strict hand hygiene, having the client demonstrate aseptic technique with dressing change, and asking the client to verbalize signs and symptoms of infection are all interventions/actions the client can take contributing to wound healing.
Subcategory- Standard Precautions/Transmission-based Precautions/Surgical Asepsis
Rationale – The goal was that wound would heal. Assessing the wound is the only option for determining healing. Asking the client if they have adhered to strict hand hygiene, having the client demonstrate aseptic technique with dressing change, and asking the client to verbalize signs and symptoms of infection are all interventions/actions the client can take contributing to wound healing.
Subcategory- Standard Precautions/Transmission-based Precautions/Surgical Asepsis
The nurse will be caring for an infant after having cleft lip/cleft palate corrective surgery. Which type of restraint will the nurse anticipate is in use when the infant returns from surgery?
Rationale – Elbow provides the least restrictive form of restraint. The goal is to keep the infant from touching mouth, dislodging IVs and tubes. Papoose, Swaddling, and mummifying unnecessarily restrict movement of all extremities.
Subcategory- Use of Restraints/Safety Devices
Rationale – Elbow provides the least restrictive form of restraint. The goal is to keep the infant from touching mouth, dislodging IVs and tubes. Papoose, Swaddling, and mummifying unnecessarily restrict movement of all extremities.
Subcategory- Use of Restraints/Safety Devices
The nurse is caring for a client in a long term care facility. The client is independently mobile and has a habit of leaving the facility unaccompanied for “a walk.” The client is observed going out of the front door of the facility and refuses to re-enter on the nurse’s request. Which of the following is the most appropriate in this situation?
Rationale – This is an assertive, non-threatening statement by the nurse. Asking the client to come back in before they get hurt, repeatedly asking the client to come inside and reminding them of how many times they have been asked are aggressive. Advising the client that if they don’t come inside you will ask for a restraint is aggressive and threatening.
Subcategory- Use of Restraints/Safety Devices
Rationale – This is an assertive, non-threatening statement by the nurse. Asking the client to come back in before they get hurt, repeatedly asking the client to come inside and reminding them of how many times they have been asked are aggressive. Advising the client that if they don’t come inside you will ask for a restraint is aggressive and threatening.
Subcategory- Use of Restraints/Safety Devices
In planning care for a client who has an ataxic gait and dementia, the nurse recognizes the need for a physical restraint to maintain the client’s safety. Which of the following is the most appropriate nursing diagnosis?
Rationale – The safety risk is the priority. The risk for injury has caused immobility. Social isolation and altered self-esteem are psychosocial and are secondary to the client’s immediate safety needs.
Subcategory- Use of Restraints/Safety Devices
Rationale – The safety risk is the priority. The risk for injury has caused immobility. Social isolation and altered self-esteem are psychosocial and are secondary to the client’s immediate safety needs.
Subcategory- Use of Restraints/Safety Devices
The Emergency Department nurse is planning discharge of a client with a fractured fibula who has had a closed reduction and application of a plaster cast to the lower leg. The nurse anticipates the health care provider to order which of the following?
Rationale – A fresh cast cannot have pressure on it while it dries. A client with a cane or crutches both include weight bearing. Unnecessarily limits client’s mobility which could lead to other complications of immobility such as decubiti, pneumonia, and deep vein thrombus.
Subcategory- Ergonomic Principles
Rationale – A fresh cast cannot have pressure on it while it dries. A client with a cane or crutches both include weight bearing. Unnecessarily limits client’s mobility which could lead to other complications of immobility such as decubiti, pneumonia, and deep vein thrombus.
Subcategory- Ergonomic Principles
A client is being discharged from the hospital with health care provider instructions for “Non-weight bearing left leg, teach crutch walking. Which type of crutch walking gait will the nurse be instructing the client?
Rationale – A three-point gait is the only crutch gait that can be used for a non-weight bearing leg. Swing through, two point, and four point gaits all require at least partial weight bearing of leg(s).
Subcategory- Ergonomic Principles
Rationale – A three-point gait is the only crutch gait that can be used for a non-weight bearing leg. Swing through, two point, and four point gaits all require at least partial weight bearing of leg(s).
Subcategory- Ergonomic Principles
The nurse is caring for a client with high dose stereotactic radioactive cerebral implants. Which of the following actions will the nurse perform to protect themselves and others from unnecessary radiation exposure? Select all that apply.
Rationale – Instructing visitors to limit time, wearing a radiation dosimeter at all times, and donning gown, gloves, and a mask are accepted guidelines for care of the client with radiation implants. Assigning the client a private room is necessary for the client with radioactive implants. Clients receiving other forms of radiation therapy are at risk for overexposure of radiation. A six-foot distance should be maintained from the client with radioactive implants not a three-foot distance.
Subcategory- Handling Hazardous and Infectious Material
Rationale – Instructing visitors to limit time, wearing a radiation dosimeter at all times, and donning gown, gloves, and a mask are accepted guidelines for care of the client with radiation implants. Assigning the client a private room is necessary for the client with radioactive implants. Clients receiving other forms of radiation therapy are at risk for overexposure of radiation. A six-foot distance should be maintained from the client with radioactive implants not a three-foot distance.
Subcategory- Handling Hazardous and Infectious Material
The nurse administering IV chemotherapeutic agents to a client drops the IV bag and it splits open, forming a large pool of fluid. What is the priority action for the nurse?
Rationale – Obtaining a spill kit is the priority since wearing 2 pairs of gloves and a gown that has no seams or closures should already be implemented if administering chemotherapeutic agents. A closed system, puncture/leak proof container would be the next priority, if linens are contaminated.
Subcategory- Handling Hazardous and Infectious Material
Rationale – Obtaining a spill kit is the priority since wearing 2 pairs of gloves and a gown that has no seams or closures should already be implemented if administering chemotherapeutic agents. A closed system, puncture/leak proof container would be the next priority, if linens are contaminated.
Subcategory- Handling Hazardous and Infectious Material
The nurse has instructed a client in the use of a heat pack to help with pain management. Which of the following statements by the client indicates teaching has been successful?
Rationale – After 30-45 minutes the rebound phenomenon occurs with tissue congestion and blood vessel constriction. A protective barrier such as a towel must be placed between the skin and the heat pack to prevent burns. 10 minutes is too brief for the therapy to be effective. If there is decreased sensory perception of affected area, applications of heat and cold are contraindicated.
Subcategory- Safe Use of Equipment
Rationale – After 30-45 minutes the rebound phenomenon occurs with tissue congestion and blood vessel constriction. A protective barrier such as a towel must be placed between the skin and the heat pack to prevent burns. 10 minutes is too brief for the therapy to be effective. If there is decreased sensory perception of affected area, applications of heat and cold are contraindicated.
Subcategory- Safe Use of Equipment
A home care nurse has completed teaching client guidelines for use of a wound VAC at home to heal a chronic wound. The nurse returns in 1 week to evaluate if the teaching was successful. Which of the following is an indicator of successful teaching?
Rationale – A decreasing wound measurement indicates progression in wound healing –the rationale for the wound VAC. Drainage decrease is expected but does not indicate success of the teaching. A client verbalizing they have the wound VAC or a client demonstrating how to check the vacuum chamber for exudate are appropriate actions on the client’s part but they do not indicate success of teaching since the expected outcome of the teaching is successful implementation of the wound VAC to promote wound healing.
Subcategory- Safe Use of Equipment
Rationale – A decreasing wound measurement indicates progression in wound healing –the rationale for the wound VAC. Drainage decrease is expected but does not indicate success of the teaching. A client verbalizing they have the wound VAC or a client demonstrating how to check the vacuum chamber for exudate are appropriate actions on the client’s part but they do not indicate success of teaching since the expected outcome of the teaching is successful implementation of the wound VAC to promote wound healing.
Subcategory- Safe Use of Equipment
A client’s health care provider has ordered a narcotic analgesic to be administered as a standing order every 8 hours. The night shift nurse notes at 2400 that the evening dose of narcotic was not given at 1600. Put the following actions the nurse will take in their priority order.
Rationale – The narcotic still needs to be administered so the nurse would get the dose ordered, assess pain and vital signs for assessment and documenting purposes, administer the ordered dose and begin notifying appropriate staff, beginning at the lowest level (supervisor first, then health care provider,) then fill out the incident report.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
Rationale – The narcotic still needs to be administered so the nurse would get the dose ordered, assess pain and vital signs for assessment and documenting purposes, administer the ordered dose and begin notifying appropriate staff, beginning at the lowest level (supervisor first, then health care provider,) then fill out the incident report.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
Which of the following is considered the best method for a nurse to verify that the correct amount of medication has been drawn up from a vial prior to administering the medication to a client?
Rationale – This is the safest method, requiring the nurse checking the dose to note the concentration of medication in the vial to determine the dose that was drawn up in the syringe. The nurse should not trust with 100% accuracy, other staff that have calculated the dose to administer. The last insurance of medication administration safety is the nurse administering the medication. Each dose to be administered should be calculated before administration by the nurse administering it. The same nurse could be making the same calculating error twice and administer the incorrect dose. The administering nurse is relying on 100% accuracy of the information they obtained regarding the dose on hand and this may be incorrect.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
Rationale – This is the safest method, requiring the nurse checking the dose to note the concentration of medication in the vial to determine the dose that was drawn up in the syringe. The nurse should not trust with 100% accuracy, other staff that have calculated the dose to administer. The last insurance of medication administration safety is the nurse administering the medication. Each dose to be administered should be calculated before administration by the nurse administering it. The same nurse could be making the same calculating error twice and administer the incorrect dose. The administering nurse is relying on 100% accuracy of the information they obtained regarding the dose on hand and this may be incorrect.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
The nurse observes the following action by staff members. Which observed action below, indicates the need for staff education?
Rationale – Severe acute respiratory syndrome requires contact and airborne precautions. Gloves must always be worn when giving injections in anticipation of exposure to blood. Blood and body fluid splash could be anticipated, requiring all four PPE items (gown, gloves, mask, and goggles. Hand hygiene is always performed after taking off gloves.
Subcategory- Standards Precautions/Transmission-based Precautions/Surgical Asepsis
Rationale – Severe acute respiratory syndrome requires contact and airborne precautions. Gloves must always be worn when giving injections in anticipation of exposure to blood. Blood and body fluid splash could be anticipated, requiring all four PPE items (gown, gloves, mask, and goggles. Hand hygiene is always performed after taking off gloves.
Subcategory- Standards Precautions/Transmission-based Precautions/Surgical Asepsis
An 88-year-old chicken farmer living in an extremely rural area two hours from the nearest health care facility is admitted to the Intensive Care Unit with sepsis. Which of the following risk factors listed below are considered primary risk factors for sepsis? Select all that apply.
Rationale- Age, medical history, and immune system status would be considered the primary risk factors for sepsis. Advanced age with aging immune system and the client’s prior medical history will be analyzed first. Then other factors such as farm environment with potential wound contamination, distance from health care, family and friends, and factors impacting immune system status.
Subcategory- Standards Precautions/Transmission-based Precautions/Surgical Asepsis
Rationale- Age, medical history, and immune system status would be considered the primary risk factors for sepsis. Advanced age with aging immune system and the client’s prior medical history will be analyzed first. Then other factors such as farm environment with potential wound contamination, distance from health care, family and friends, and factors impacting immune system status.
Subcategory- Standards Precautions/Transmission-based Precautions/Surgical Asepsis
The nurse is assessing client data to determine if they meet the criteria for systemic inflammatory response syndrome (SIRS). Which of the following data would the nurse disregard in this assessment?
Rationale- The pulse criteria for SIRS is >90/min. PaCO2 < 32 mm Hg, Temperature > 100.40F, and White blood cell count >12,000 cells/mm3
Subcategory- Standards Precautions/Transmission-based Precautions/Surgical Asepsis
Rationale- The pulse criteria for SIRS is >90/min. PaCO2 < 32 mm Hg, Temperature > 100.40F, and White blood cell count >12,000 cells/mm3
Subcategory- Standards Precautions/Transmission-based Precautions/Surgical Asepsis
Which of the following restraints or safety devices is the least restrictive for a client who is at high risk for falls that repeatedly gets out of bed without an assist?
Rationale – Implementing a functioning bed alarm is the least restrictive allowing movement, yet alerting staff when client is out of bed. Applying bilateral restraints and vest restraint are physical restraints restricting access to body and movement. In a PRN, order for clonazepam is a chemical restraint, also restrictive.
Subcategory- Use of Restraints/Safety Devices
Rationale – Implementing a functioning bed alarm is the least restrictive allowing movement, yet alerting staff when client is out of bed. Applying bilateral restraints and vest restraint are physical restraints restricting access to body and movement. In a PRN, order for clonazepam is a chemical restraint, also restrictive.
Subcategory- Use of Restraints/Safety Devices
A health care provider in an inpatient psychiatric facility has given a verbal order to apply a vest and bilateral wrist restraints on a client who has become extremely violent. The nurse recognizes that the restraints must be applied immediately and writes a verbal order from the health care provider. Within what maximum time frame must the health care provider sign this original order for these restraints?
Rationale – 24 hours is the maximum time frame required by law.
Subcategory – Use of restraints/Safety devices
Rationale – 24 hours is the maximum time frame required by law.
Subcategory – Use of restraints/Safety devices
An adult client is pulling at their IV lines and enteral tubes. Which of the following restraints will the nurse suggest to the health care provider to order as being the most appropriate?
Rationale – Bilateral hand mitts maintain mobility of shoulders, elbows, and wrists while preventing the fine finger movement needed to pull out tubes and lines. A vest restraint will not prevent client from pulling out tubes and lines. Bilateral wrist restraints restrict shoulder and elbow movement. Bilateral elbow restraints restrict elbow movements.
Subcategory – Use of restraints/Safety devices
Rationale – Bilateral hand mitts maintain mobility of shoulders, elbows, and wrists while preventing the fine finger movement needed to pull out tubes and lines. A vest restraint will not prevent client from pulling out tubes and lines. Bilateral wrist restraints restrict shoulder and elbow movement. Bilateral elbow restraints restrict elbow movements.
Subcategory – Use of restraints/Safety devices