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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.
-The “NCLEX Cracker” Team
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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What food selections demonstrate the clients understanding nutrition related to heart failure? Select all that apply.
Rationale – A client with a history of heart failure should be eating a heart healthy diet that includes low-sodium meals rich in vitamins and minerals such as grilled chicken salad, a banana and skim milk. Potato chips and diet soda are both high in sodium and should not be included on heart healthy diet.
Subcategory – Nutrition
Rationale – A client with a history of heart failure should be eating a heart healthy diet that includes low-sodium meals rich in vitamins and minerals such as grilled chicken salad, a banana and skim milk. Potato chips and diet soda are both high in sodium and should not be included on heart healthy diet.
Subcategory – Nutrition
While auscultating a client’s left lower lobe the nurse here’s adventitious lung sounds. What is the first step in determining whether this is an abnormality?
Rationale – It is important if an abnormality is auscultated on one side to compare the sounds on the opposite side. They do not need to ask a client about abnormal lung sounds. Listening at a later time will not necessarily have the same assessment findings. The nurse does not need to inform forget the healthcare provider to listen and verify their findings.
Subcategory – Assessment findings
Rationale – It is important if an abnormality is auscultated on one side to compare the sounds on the opposite side. They do not need to ask a client about abnormal lung sounds. Listening at a later time will not necessarily have the same assessment findings. The nurse does not need to inform forget the healthcare provider to listen and verify their findings.
Subcategory – Assessment findings
What form of non-pharmacological pain relief is suggested for soothing newborns and comatose clients?
Rationale – Music is a form of distraction I can be used with newborns and comatose clients. Distraction is not possible as a comatose patient newborn cannot communicate. Humor likely would not be understood by newborn or comatose clients. Imagery is not effective with newborns or comatose clients. Acupuncture would likely increase agitation rather than.
Subcategory – Non-pharmacological comfort interventions
Rationale – Music is a form of distraction I can be used with newborns and comatose clients. Distraction is not possible as a comatose patient newborn cannot communicate. Humor likely would not be understood by newborn or comatose clients. Imagery is not effective with newborns or comatose clients. Acupuncture would likely increase agitation rather than.
Subcategory – Non-pharmacological comfort interventions
A client that has been NPO with only intravenous fluids for a prolonged period may exhibit what signs and symptoms of protein – calorie malnutrition? Select all that apply.
Rationale – Clients with protein calorie malnutrition may exhibit signs of poor wound healing, edema and apathy. Vomiting and Weight gain are not signs of protein – calorie malnutrition.
Subcategory – Nutrition
Rationale – Clients with protein calorie malnutrition may exhibit signs of poor wound healing, edema and apathy. Vomiting and Weight gain are not signs of protein – calorie malnutrition.
Subcategory – Nutrition
The client diagnosed with Pellagra would benefit from which of the following food selections?
Rationale – Tuna and green peas are both high in niacin which is deficient in clients with this disorder. Whole grains are fortified move milk, citrus fruits and strawberries and pasta with meat sauce do not have as high value of niacin as the tuna and green peas.
Subcategory – Nutrition
Rationale – Tuna and green peas are both high in niacin which is deficient in clients with this disorder. Whole grains are fortified move milk, citrus fruits and strawberries and pasta with meat sauce do not have as high value of niacin as the tuna and green peas.
Subcategory – Nutrition
The client was celiac disease has been diagnosed with malabsorption syndrome. The nurse is observing the client for signs and symptoms of vitamin deficiencies that may occur with this disorder. What findings with the nurse expect to observe?
Rationale – Fatigue is a sign often associated with iron deficiency which is one of the most common deficiencies seen in celiac disease. Clients would not experience renal calculi. They would often exhibit hypotension and weight loss.
Subcategory – Nutrition
Rationale – Fatigue is a sign often associated with iron deficiency which is one of the most common deficiencies seen in celiac disease. Clients would not experience renal calculi. They would often exhibit hypotension and weight loss.
Subcategory – Nutrition
The parents of an eight-year-old son are concerned about his somnambulism. What topic is priority for the nurse to discuss with these parents?
Rationale – Safety is a priority topic that should be discussed with the family of a child who is sleepwalking. Nutrition is not a priority. Sleep needs may be discussed as well as schoolwork but safety is still the priority.
Subcategory – Sleep and Rest
Rationale – Safety is a priority topic that should be discussed with the family of a child who is sleepwalking. Nutrition is not a priority. Sleep needs may be discussed as well as schoolwork but safety is still the priority.
Subcategory – Sleep and Rest
What Foods or drinks can be recommended to a client with sleep problems?
Rationale – A carbohydrate snack may help promote sleep and clients who are having difficulty falling asleep or staying asleep. High-protein foods red wine and hot tea or not indicated for assistance with sleep.
Subcategory – Sleep and Rest
Rationale – A carbohydrate snack may help promote sleep and clients who are having difficulty falling asleep or staying asleep. High-protein foods red wine and hot tea or not indicated for assistance with sleep.
Subcategory – Sleep and Rest
The nurse is caring for the following for clients. Which client is most appropriate to use a four-point gait while utilizing crutches?
Rationale – A client utilizing a four-point gate has to be partially weight-bearing on both legs. It is the safest gait and provide three points of support. The client they can only bear weight on one leg would need to utilize a three-point gait. The client they can bear weight on both feet would use a swing to gait. A client that he is utilizing assistive device is for balance and support.
Subcategory – Assistive Devices
Rationale – A client utilizing a four-point gate has to be partially weight-bearing on both legs. It is the safest gait and provide three points of support. The client they can only bear weight on one leg would need to utilize a three-point gait. The client they can bear weight on both feet would use a swing to gait. A client that he is utilizing assistive device is for balance and support.
Subcategory – Assistive Devices
A client with a new prescription for a cane to help with balance and support is being fitted. What length is appropriate for the use of a cane?
Rationale – A cane should allow for the client just slightly bend her elbow while utilizing the cane. It does not need to rest at the top of the femur. It should not be 1 inch below the umbilicus in the handle does not need to be midway between axilla in the knee.
Subcategory – Assistive Devices
Rationale – A cane should allow for the client just slightly bend her elbow while utilizing the cane. It does not need to rest at the top of the femur. It should not be 1 inch below the umbilicus in the handle does not need to be midway between axilla in the knee.
Subcategory – Assistive Devices
The client diagnosed with constipation has received teaching regarding food selections to help improve bowel function. What selections by the client indicates the teaching was effective? Select all that apply.
Rationale – Bran, prunes, and figs have been shown to have laxative effects and improve constipation in clients. Cheese and eggs both have constipating effects.
Subcategory – Elimination
Rationale – Bran, prunes, and figs have been shown to have laxative effects and improve constipation in clients. Cheese and eggs both have constipating effects.
Subcategory – Elimination
A hospitalized client has received teaching on how to utilize a bedpan for a bowel movement. What statement by the client indicates a need for further teaching?
Rationale – There and I will help pass the stool and promote defecation. The client should flex Thigh muscles as this increases intra-abdominal pressure. Bending their knees will help with positioning. Sitting position is indicated for clients utilizing a bedpan.
Subcategory – Elimination
Rationale – There and I will help pass the stool and promote defecation. The client should flex Thigh muscles as this increases intra-abdominal pressure. Bending their knees will help with positioning. Sitting position is indicated for clients utilizing a bedpan.
Subcategory – Elimination
A client being seen for excessive flatulence has received teaching regarding methods to decrease flatulence. What statement by the client indicates a need for further teaching?
Rationale – Drinking through a straw will increase gas therefore increased flatulence. The client should be instructed not to chew gum as much if at all. They should decrease the amount of carbonated beverages and avoid foods that increase gas such as cabbage and onions.
Subcategory – Elimination
Rationale – Drinking through a straw will increase gas therefore increased flatulence. The client should be instructed not to chew gum as much if at all. They should decrease the amount of carbonated beverages and avoid foods that increase gas such as cabbage and onions.
Subcategory – Elimination
The nurse has provided teaching regarding foods that cause odor to a client with a new colostomy. When asked what foods will increase odor, what selections indicate the client understands the teaching? Select all that apply.
Rationale – Asparagus, eggs and fish all increase odor of the stool and clients with ostomies. Chocolate may cause loose stools and bananas may cause six stools.
Subcategory – Elimination
Rationale – Asparagus, eggs and fish all increase odor of the stool and clients with ostomies. Chocolate may cause loose stools and bananas may cause six stools.
Subcategory – Elimination
A client diagnosed with urinary retention should be assessed for taking what medications? Select all that apply.
Rationale – Anticholinergics, antidepressants and anti-pretenses have all been shown to lead to urinary retention. Antidiabetic and anti-thyroid agents do not increase the risk of urinary retention.
Subcategory – Elimination
Rationale – Anticholinergics, antidepressants and anti-pretenses have all been shown to lead to urinary retention. Antidiabetic and anti-thyroid agents do not increase the risk of urinary retention.
Subcategory – Elimination
What findings are consistent with a client diagnosed with a lower urinary tract infection? Select all that apply.
Rationale – Pyuria, dysuria and frequency are all common findings with your lower urinary tract infections. Diarrhea and flank pain are often seen with upper urinary tract infections.
Subcategory – Elimination
Rationale – Pyuria, dysuria and frequency are all common findings with your lower urinary tract infections. Diarrhea and flank pain are often seen with upper urinary tract infections.
Subcategory – Elimination
The nurse is observing an unlicensed assistive personnel washing the eyes of a client. What action by the UAP indicates a need for further teaching?
Rational – When cleansing a client’s eyes, the nurse or UAP should wait away from the intercampus. Water only should be used. Separate corners of the washcloths should be used for each eye and they should be dried after cleansing.
Subcategory – Hygiene
Rational – When cleansing a client’s eyes, the nurse or UAP should wait away from the intercampus. Water only should be used. Separate corners of the washcloths should be used for each eye and they should be dried after cleansing.
Subcategory – Hygiene
A nurse is providing perineal care to a female client. After placing the client on their back with knees flexed and spread apart what actions by the nurse are appropriate?
Rationale – The nurse should rinse the area well by either porn warm water or using a clean washcloth after cleansing. The nurse should always wipe from front to back. The labia majora should be cleaned first then between the folds.
Subcategory – Hygiene
Rationale – The nurse should rinse the area well by either porn warm water or using a clean washcloth after cleansing. The nurse should always wipe from front to back. The labia majora should be cleaned first then between the folds.
Subcategory – Hygiene
The nurse is caring for the following for clients. Which client has the most significant effect of immobility?
Rationale – A client who has fixed the plantar flexion is experiencing foot drop. That is one of the most significant effects of immobility. The client with a low albumin level may be treated. A client with decreased strength may regain their strength. A client that requires assistance getting in and out of bed may regain their strength.
Subcategory – Immobility
Rationale – A client who has fixed the plantar flexion is experiencing foot drop. That is one of the most significant effects of immobility. The client with a low albumin level may be treated. A client with decreased strength may regain their strength. A client that requires assistance getting in and out of bed may regain their strength.
Subcategory – Immobility
A client with uncontrolled hypertension states that he does not believe in taking oral medications as prescribed by his health care provider. He has however been participating in acupuncture treatments. Of the interventions below what would best assist this client? Select all that apply.
Rationale – The client’s blood pressure should be closely monitored to be sure that a hypertensive crisis does not occur. Also, the prescriber should be notified that the client has not been compliant with regards to the medications regimen. Discharging the client will not help to control blood pressure. Subscribing to the patient’s belief will not allow for adequate blood pressure control.
Subcategory – Lifestyle Choices
Rationale – The client’s blood pressure should be closely monitored to be sure that a hypertensive crisis does not occur. Also, the prescriber should be notified that the client has not been compliant with regards to the medications regimen. Discharging the client will not help to control blood pressure. Subscribing to the patient’s belief will not allow for adequate blood pressure control.
Subcategory – Lifestyle Choices
While caring for a client with a darker pigment what method should the nurse utilize to assess for cyanosis?
Rationale – An early sign of cyanosis on a client of darker pigment is indicated by looking at the oral mucosa. Dyspnea is not going to indicate cyanosis; cyanosis is the bluish coloring that is found in the skin or oral mucosal. The lips are not the best indicator of cyanosis and the nail bed maybe a later sign of cyanosis. Hourly vital signs are not indicative of cyanosis.
Subcategory – Techniques for Physical Assessment
Rationale – An early sign of cyanosis on a client of darker pigment is indicated by looking at the oral mucosa. Dyspnea is not going to indicate cyanosis; cyanosis is the bluish coloring that is found in the skin or oral mucosal. The lips are not the best indicator of cyanosis and the nail bed maybe a later sign of cyanosis. Hourly vital signs are not indicative of cyanosis.
Subcategory – Techniques for Physical Assessment
A pregnant woman is receiving education regarding actions to take if she experiences signs of preterm labor. What action by the client indicates a need for further teaching? Select all that apply.
Rationale – The client should lie in the left lateral position. They should increase fluid intake by 3 to 4 glasses. They should also empty their bladder. The nurse should monitor for any signs of ruptured membranes. They should notify the healthcare provider if they are contractions are closer than 10 minutes.
Subcategory – Pregnancy
Rationale – The client should lie in the left lateral position. They should increase fluid intake by 3 to 4 glasses. They should also empty their bladder. The nurse should monitor for any signs of ruptured membranes. They should notify the healthcare provider if they are contractions are closer than 10 minutes.
Subcategory – Pregnancy
A pregnant mother is 11 weeks gestation with a BMI of 23. What weight gain is recommended during her pregnancy?
Rationale – A client with a normal BMI should have a weight gain of approximately 3 1/2 pounds per month in the second and third trimesters. 15 to 18 pounds is not enough. The weight gain of 10 to 12 pounds during the first trimester is too much. Weight gain of 1 1/2 to 2 pounds is too much during the second and third trimester.
Subcategory – Pregnancy
Rationale – A client with a normal BMI should have a weight gain of approximately 3 1/2 pounds per month in the second and third trimesters. 15 to 18 pounds is not enough. The weight gain of 10 to 12 pounds during the first trimester is too much. Weight gain of 1 1/2 to 2 pounds is too much during the second and third trimester.
Subcategory – Pregnancy
What is the most important nursing intervention in breaking the chain of infection?
Rationale – The most important component of breaking the chain of infection is proper hand hygiene. Wearing gloves is important however hand hygiene is priority. Client education is also important; however, hand hygiene is the most effective. Administering medications does not break the chain of infection.
Subcategory – Self Care
Rationale – The most important component of breaking the chain of infection is proper hand hygiene. Wearing gloves is important however hand hygiene is priority. Client education is also important; however, hand hygiene is the most effective. Administering medications does not break the chain of infection.
Subcategory – Self Care
While assessing a newborn immediately after birth, the nurse documents that the Apgar score is normal. What score is consistent with this finding?
Rationale – Apgar scores are based on a 1 to 10 scale. Two and four would indicate low scores at seven, eight or nine are normal and are assigned that the newborn is in good health, twelve would not be a valid Apgar score.
Subcategory – Health Promotion
Rationale – Apgar scores are based on a 1 to 10 scale. Two and four would indicate low scores at seven, eight or nine are normal and are assigned that the newborn is in good health, twelve would not be a valid Apgar score.
Subcategory – Health Promotion
The mother of a newborn child calls the pediatrician’s office with concern that her child is often jolted or startled when you’re waking from sleep. What reflex is the mother likely witnessing?
Rationale – The Moro reflex is a startle reflex went to loud noise or sudden change in position occurs and is often seen until about the age of six months. Routing is when the side of the mouth is touched in infant turns to that side. Babinski’s is the fanning of the toes when the sole of the foot is stroked. Tonic neck is the fencing position when their head is turned to the side.
Subcategory – Health Promotion
Rationale – The Moro reflex is a startle reflex went to loud noise or sudden change in position occurs and is often seen until about the age of six months. Routing is when the side of the mouth is touched in infant turns to that side. Babinski’s is the fanning of the toes when the sole of the foot is stroked. Tonic neck is the fencing position when their head is turned to the side.
Subcategory – Health Promotion
A mother has received teaching regarding nutritional needs of her newborn child. What statement by the mother indicates a need for further teaching?
Rationale – Eggs and wheat products have high allergy risks and should not be introduced until the child is at least 2 to 3 years of age. Babies can have meats about 8 to 10 months, they may have fruits or vet vegetables at about 6 to 8 months and they can have rice cereal at about six months.
Subcategory – Health Promotion and Maintenance
Rationale – Eggs and wheat products have high allergy risks and should not be introduced until the child is at least 2 to 3 years of age. Babies can have meats about 8 to 10 months, they may have fruits or vet vegetables at about 6 to 8 months and they can have rice cereal at about six months.
Subcategory – Health Promotion and Maintenance
What age would a client be concerned about generativity, feeling needed in being vital in establishing the nurturing of the next generation?
Rationale – According to Erickson’s middle age adults struggle with generativity versus stagnation where they are searching to provide for others to be successful and establish and nurture the next generation.
Subcategory – Health Promotion
Rationale – According to Erickson’s middle age adults struggle with generativity versus stagnation where they are searching to provide for others to be successful and establish and nurture the next generation.
Subcategory – Health Promotion
What signs and symptoms are consistent with a client who has an altered self-concept? Select all that apply.
Rationale – Clients with altered self-concept often have inappropriate anger, lack of eye contact and put themselves down sometimes in the form of jokes. They are usually dependent not independent and are very delayed in making decisions.
Subcategory – Health Promotion
Rationale – Clients with altered self-concept often have inappropriate anger, lack of eye contact and put themselves down sometimes in the form of jokes. They are usually dependent not independent and are very delayed in making decisions.
Subcategory – Health Promotion
A client admitted to the unit has just received a tray. The client is scheduled for a full liquid diet. What food selections should be removed from the tray prior to bringing it in the client’s room? Select all that apply.
Rationale – Scrambled eggs and mashed potatoes are not included on a full liquid diet. Custard, ice cream and use are all components of a full liquid diet.
Subcategory – Nutrition
Rationale – Scrambled eggs and mashed potatoes are not included on a full liquid diet. Custard, ice cream and use are all components of a full liquid diet.
Subcategory – Nutrition
The nurses providing teaching regarding nutrition and lowering risk of cancer. What selections by the client indicates the teaching was effective? Select all that apply.
Rationale – To decrease the risk of cancer it is important to increase fiber, decreased fat and decrease alcohol consumption. It is recommended to switch away from animal-based foods into plant-based foods. It is also recommended to decrease calorie consumption.
Subcategory – Disease Promotion
Rationale – To decrease the risk of cancer it is important to increase fiber, decreased fat and decrease alcohol consumption. It is recommended to switch away from animal-based foods into plant-based foods. It is also recommended to decrease calorie consumption.
Subcategory – Disease Promotion
A client that has experienced a myocardial infarction is being taught lake so modifications during the healing process. What actions by the client indicates the teaching was effective? Select all that apply.
Rationale – It is important for clients to avoid extreme cold. They should participate in a weight-loss program and smoking cessation. It is contraindicated to eat large meals. Blood pressure medication should be taken on a continual basis to avoid high blood pressure, not when blood pressure is elevated.
Subcategory – High Risk Behaviors
Rationale – It is important for clients to avoid extreme cold. They should participate in a weight-loss program and smoking cessation. It is contraindicated to eat large meals. Blood pressure medication should be taken on a continual basis to avoid high blood pressure, not when blood pressure is elevated.
Subcategory – High Risk Behaviors
What action by an 11-year-old client demonstrates formal operational thought according to Piaget?
Rationale – According to Piaget the ability to think about concepts and analyzing a situation demonstrates formal operational thought. Formal operational thought is not understanding cause and effect, asking indirect questions or associating symbolism.
Subcategory – Health Promotion and Maintenance
Rationale – According to Piaget the ability to think about concepts and analyzing a situation demonstrates formal operational thought. Formal operational thought is not understanding cause and effect, asking indirect questions or associating symbolism.
Subcategory – Health Promotion and Maintenance
The nurse is caring for an infant that was brought to the emergency room with a diagnosis of malnutrition. The nurse identifies that the infant is likely experiencing what component of the stages of development?
Rationale – An infant whose needs are not met will often be experiencing mistrust. Isolation, initiative, and generativity are not components of the stages of development for an infant.
Subcategory – Health Promotion and Maintenance
Rationale – An infant whose needs are not met will often be experiencing mistrust. Isolation, initiative, and generativity are not components of the stages of development for an infant.
Subcategory – Health Promotion and Maintenance
A client diagnosed with vitamin K deficiency has received teaching regarding nutrition with this disorder. What food selections by the client demonstrate an understanding of the teaching provided?
Rationale –Brussels sprouts in olive oil are both high in vitamin K. Lean meats and corn, organ meats and carrots, and whole grains and skim milk or not high in vitamin K.
Subcategory – Health Promotion and Maintenance
Rationale –Brussels sprouts in olive oil are both high in vitamin K. Lean meats and corn, organ meats and carrots, and whole grains and skim milk or not high in vitamin K.
Subcategory – Health Promotion and Maintenance
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 – Accident/Error and Injury Prevention
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 – Accident/Error and Injury Prevention
A 72 year-old client becomes increasingly agitated and is trying to climb over the bed rails 3 hours after returning from surgery to repair an abdominal hernia. Which is the best action by the nurse?
Rationale – The client requires more frequent nurse encounters to ensure safety. Speaking to family will not ensure safety and could further agitate them. Less frequent nurse encounters is not safe. Though this may decrease agitation, it is not the safest choice for a client trying to climb over bed rails.
Subcategory – Accident/Error and Injury Prevention
Rationale – The client requires more frequent nurse encounters to ensure safety. Speaking to family will not ensure safety and could further agitate them. Less frequent nurse encounters is not safe. Though this may decrease agitation, it is not the safest choice for a client trying to climb over bed rails.
Subcategory – Accident/Error and Injury Prevention
The parents of a newborn state “We know lead poisoning is dangerous. How will we know if this is a problem for our baby? Which of the following would be the nurse’s best response?
Rationale – Lead poisoning often has no noted signs, making the risks higher. Older homes are not the singular risk for lead poisoning. Toys, newsprint and lead pipes also pose risks for lead poisoning. A newborn cannot explain pain and often, lead poisoning has no alerting symptoms before physical damage occurs. Lead screening is usually first performed at 6 or nine months of age, and again between 18 months and two years old.
Subcategory – Accident/Error and Injury Prevention
Rationale – Lead poisoning often has no noted signs, making the risks higher. Older homes are not the singular risk for lead poisoning. Toys, newsprint and lead pipes also pose risks for lead poisoning. A newborn cannot explain pain and often, lead poisoning has no alerting symptoms before physical damage occurs. Lead screening is usually first performed at 6 or nine months of age, and again between 18 months and two years old.
Subcategory – Accident/Error and Injury Prevention
The nurse is speaking with a parent of a teenage boy who is experiencing temporary quadriplegia as result of a bruised spinal cord. The parent asks “How will he let you know when he needs anything?” Which of the following is the most appropriate response by the nurse?
Rationale – The client must have a means to call staff and a tap bell is not appropriate for a client experiencing quadriplegia. The remaining options are poor use of resources.
Subcategory – Accident/Error and Injury Prevention
Rationale – The client must have a means to call staff and a tap bell is not appropriate for a client experiencing quadriplegia. The remaining options are poor use of resources.
Subcategory – Accident/Error and Injury Prevention
Which of the following concepts does the nurse recognize as being the priority in any disaster preparation planning?
Rationale – Preparing for disasters is the most important concept which incorporates all the other options.
Subcategory – Emergency response plan
Rationale – Preparing for disasters is the most important concept which incorporates all the other options.
Subcategory – Emergency response plan
Following a disaster, critical incident management teams conduct 2-3 hour sessions where victims are asked to verbalize their emotional responses to the disaster and any symptoms they may be experiencing as a result of the disaster. The nurse recognizes these sessions as what component of critical incident management?
Rationale – This is the process of debriefing. Defusing is a 20-40 minute group process that occurs within the first 12 hours after a critical incident. This is usually conducted in units. Demobilizing is as personnel are discharged from the scene of the disaster, they participate in a session including education, rest, and nutrition. 4Support services are provided to command staff and personnel operating at the scene of an emergency following such incidents as prolonged extrications or line of duty death.
Subcategory – Emergency response plan
Rationale – This is the process of debriefing. Defusing is a 20-40 minute group process that occurs within the first 12 hours after a critical incident. This is usually conducted in units. Demobilizing is as personnel are discharged from the scene of the disaster, they participate in a session including education, rest, and nutrition. 4Support services are provided to command staff and personnel operating at the scene of an emergency following such incidents as prolonged extrications or line of duty death.
Subcategory – Emergency response plan
A client is returning from an endoscopic procedure on a stretcher. Which of the following actions by the nurse is most appropriate when transferring the client to the bed?
Rationale – A stretcher to bed transfer should never be attempted by a single staff member. Endoscopy requires sedation –it is not safe for client to stand and pivot to the bed or ask the client to move to the bed.
Subcategory – Ergonomic Principles
Rationale – A stretcher to bed transfer should never be attempted by a single staff member. Endoscopy requires sedation –it is not safe for client to stand and pivot to the bed or ask the client to move to the bed.
Subcategory – Ergonomic Principles
A nurse in a rehabilitation facility is anticipating the discharge of a client recovering from Guillain-Barre syndrome. The client has residual equal bilateral leg weakness. Physical Therapy staff has introduced the use of Lofstrand crutches to the client for mobility. Which of the following crutch gaits does the nurse recognize as the sagest for the client to use?
Rationale – Requires weight bearing ability of both legs and provides the constant stability of three points at all times. A swing-to gait is appropriate for the client with paralysis of the legs and hips. A Three-point gain is appropriate for clients unable to bear weight on one leg. A two-point alternate gain can be used by this client and is faster than the four-point alternate gait, but requires balance since there are only two points of support in this gait.
Subcategory – Ergonomic Principles
Rationale – Requires weight bearing ability of both legs and provides the constant stability of three points at all times. A swing-to gait is appropriate for the client with paralysis of the legs and hips. A Three-point gain is appropriate for clients unable to bear weight on one leg. A two-point alternate gain can be used by this client and is faster than the four-point alternate gait, but requires balance since there are only two points of support in this gait.
Subcategory – Ergonomic Principles
The nurse has completed teaching a client with a cast on their leg how to get out of a chair with the use of crutches. Place the following steps in order that indicates teaching has been successful.
Subcategory – Ergonomic Principles
Subcategory – Ergonomic Principles
The nurse is planning to assist a client to transfer from the bed to a wheelchair. The client has left hemiparesis. Which of the following wheelchair placements will the nurse implement as the safest transfer?
Rationale – The client should transfer out of bed and pivot transfer on their stronger side (right), leaving only one correct option.
Subcategory – Ergonomic Principles
Rationale – The client should transfer out of bed and pivot transfer on their stronger side (right), leaving only one correct option.
Subcategory – Ergonomic Principles
The nurse is planning to assist a client with a half leg cast to go up a flight of stairs using crutches. Where will the nurse place themselves in relation to the client?
Rationale – Assisting the client from behind to the affected side will allow the nurse to offer the client the best support should the client misstep. The client is more likely to fall backward than forward when climbing stairs with crutches.
Subcategory – Ergonomic Principles
Rationale – Assisting the client from behind to the affected side will allow the nurse to offer the client the best support should the client misstep. The client is more likely to fall backward than forward when climbing stairs with crutches.
Subcategory – Ergonomic Principles
The nurse is planning to assist a client with a half leg cast to go down a flight of stairs using crutches. Where will the nurse place themselves in relation to the client?
Rationale – This will allow the nurse to offer the client the best support should the client misstep. The client is more likely to fall forward than backward when descending stairs with crutches. Handling hazardous and infectious material.
Subcategory – Ergonomic Principles
Rationale – This will allow the nurse to offer the client the best support should the client misstep. The client is more likely to fall forward than backward when descending stairs with crutches. Handling hazardous and infectious material.
Subcategory – Ergonomic Principles
The nurse discovers a fire in the bathroom of a client who is in bed and receiving oxygen therapy. What is the nurse’s priority action?
Rationale – The highly flammable nature of oxygen dictates the nurse terminate the oxygen supply, preventing possible injury to the client and others in the hospital. Other answer options are not safe in this situation.
Subcategory – Ergonomic Principles
Rationale – The highly flammable nature of oxygen dictates the nurse terminate the oxygen supply, preventing possible injury to the client and others in the hospital. Other answer options are not safe in this situation.
Subcategory – Ergonomic Principles
The nurse is preparing to obtain a stool sample for culture from a client with a suspected Clostridium difficile infection. What is the most important step in obtaining the stool sample that protects other clients from harmful exposure to the infectious organism?
Rationale – Mechanical removal of organisms is the only accepted method of hand sanitizing after exposure to feces infected with this organisms. Donning clean gloves and using hand sanitizer do not protect other clients. Hand sanitizing is accepted upon entering only.
Subcategory – Ergonomic Principles
Rationale – Mechanical removal of organisms is the only accepted method of hand sanitizing after exposure to feces infected with this organisms. Donning clean gloves and using hand sanitizer do not protect other clients. Hand sanitizing is accepted upon entering only.
Subcategory – Ergonomic Principles
The nurse has completed instructing a UAP on precautions to take in caring for a client who has received intravascular chemotherapy. Which statement by the UAP indicates teaching has been successful?
Rationale – The hazardous chemotherapeutic agent will be excreted for up to six hours after the treatment. Completely flushing the toilet after each use wiping down the toilet do not address the risk of the hazardous chemicals in the toilet. There is no risk to the UAP in assisting the client to the bathroom.
Subcategory – Ergonomic Principles
Rationale – The hazardous chemotherapeutic agent will be excreted for up to six hours after the treatment. Completely flushing the toilet after each use wiping down the toilet do not address the risk of the hazardous chemicals in the toilet. There is no risk to the UAP in assisting the client to the bathroom.
Subcategory – Ergonomic Principles
The nurse is preparing to obtain a fecal sample from a client who is incontinent. The nurse recognizes that a number of steps will need to be implemented to obtain the fecal sample. Place the following steps in the order of their implementation.
Rationale – Fecal material presents a biohazard. The first three steps are standard with any procedure. Gloves should be donned after gown so glove cuffs are over gown.
Subcategory – Ergonomic Principles
Rationale – Fecal material presents a biohazard. The first three steps are standard with any procedure. Gloves should be donned after gown so glove cuffs are over gown.
Subcategory – Ergonomic Principles
A client has been blinded by a chemical explosion and is nearing discharge. The client’s spouse asks “How can I help them be safe at home? Which of the following are the best for the nurse to suggest? Select all that apply.
Rationale – Removing rugs from the home, maintaining a consistent floor plan throughout the house, and a consistent arrangement of refrigerated items provide safe conditions in the home. Posting a sign can pose a home safety threat from outside intruders. Installing a ramp leading to the front door, and moving the client’s bedroom to the ground floor would be appropriate only if mobility was a challenge.
Subcategory – Home safety
Rationale – Removing rugs from the home, maintaining a consistent floor plan throughout the house, and a consistent arrangement of refrigerated items provide safe conditions in the home. Posting a sign can pose a home safety threat from outside intruders. Installing a ramp leading to the front door, and moving the client’s bedroom to the ground floor would be appropriate only if mobility was a challenge.
Subcategory – Home safety
A 36 year-old client diagnosed with schizoaffective disorder lives with their parents. The parents report they fear for their safety at home. Which of the following is the best initial response by the nurse?
Rationale – If this is “voluntary” then the client recognizes a problem and is willing to seek treatment. Chemical restraint violates the client rights. The client can be forcibly removed, though not the optimal choice since this could escalate client behaviors. Respite care is not an appropriate suggestion; the safety issue is the priority.
Subcategory – Home safety
Rationale – If this is “voluntary” then the client recognizes a problem and is willing to seek treatment. Chemical restraint violates the client rights. The client can be forcibly removed, though not the optimal choice since this could escalate client behaviors. Respite care is not an appropriate suggestion; the safety issue is the priority.
Subcategory – Home safety
A homecare nurse discovers their client in tears. The client reports their brother was visiting yesterday and “beat me up. I’m afraid he’ll come back.” Which of the following is the best response by the nurse?
Rationale – The priority is to assess the client for injuries. The client’s immediate health needs precede any legal action or law enforcement intervention. Analyzing precipitating factors is not appropriate in this crisis situation.
Subcategory – Home safety
Rationale – The priority is to assess the client for injuries. The client’s immediate health needs precede any legal action or law enforcement intervention. Analyzing precipitating factors is not appropriate in this crisis situation.
Subcategory – Home safety
A client with cranial nerve I dysfunction related to an open head injury is readying for discharge home. Which of the following will the nurse include in the discharge teaching for this client? Select all that apply.
Rationale – Inspecting all food for signs of decay will help prevent further complications. Installing smoke detectors is recommended. Keeping leftovers for longer than 3 days increases the risk of decay in food and reviewing expiration dates will also prevent consuming expired products. All protect client from harm resulting from having no sense of smell. Deli meat, fresh fruit or vegetables can be consumed if deemed safe.
Subcategory – Home safety
Rationale – Inspecting all food for signs of decay will help prevent further complications. Installing smoke detectors is recommended. Keeping leftovers for longer than 3 days increases the risk of decay in food and reviewing expiration dates will also prevent consuming expired products. All protect client from harm resulting from having no sense of smell. Deli meat, fresh fruit or vegetables can be consumed if deemed safe.
Subcategory – Home safety
A nurse discovers they have administered an incorrect medication to a client. Which of the guidelines below should the nurse follow? Select all that apply.
Answer- 2,4,5
Rationale – No medication should be administered until the healthcare provider has been notified of the error and determines what course of action should be taken. An incident report is for internal hospital use only and is not placed in the client’s medical record. An incident report should be completed as soon as possible after the incident.
Subcategory – Report of Incident/event/irregular Occurrence/Variance
Answer- 2,4,5
Rationale – No medication should be administered until the healthcare provider has been notified of the error and determines what course of action should be taken. An incident report is for internal hospital use only and is not placed in the client’s medical record. An incident report should be completed as soon as possible after the incident.
Subcategory – Report of Incident/event/irregular Occurrence/Variance
The nurse enters a client room and finds them with their head under the tied strap of a wrist restraint, cyanotic, and without respirations or pulse. The nurse releases the restraint, yells “Call a code blue!” and begins chest compressions until the code team arrives. Which of the following is the most appropriate entry into the client’s medical record?
Rationale – Documentation of events must be factual and accurate. All other options make assumptions or omitted details.
Subcategory – Report of Incident/event/irregular Occurrence/Variance
Rationale – Documentation of events must be factual and accurate. All other options make assumptions or omitted details.
Subcategory – Report of Incident/event/irregular Occurrence/Variance
The nurse notes a spark when plugging an IV infusion device into an electrical outlet for use in initiating IV fluid replacement. The nurse observes the same findings when trying to plug the device into another outlet. What is the next action the nurse should take?
Rationale –The provider’s order must still be implemented so a new IV infusion device is needed but not before taking the faulty device out of service to prevent injury to other clients and staff. Using the device on battery power until another is delivered or continuing use of the sparking device are not safe.
Subcategory – Safe use of equipment
Rationale –The provider’s order must still be implemented so a new IV infusion device is needed but not before taking the faulty device out of service to prevent injury to other clients and staff. Using the device on battery power until another is delivered or continuing use of the sparking device are not safe.
Subcategory – Safe use of equipment
Which of the following clients does the nurse recognize as being at highest risk for bacteremia?
Rationale – The possibility of a bloodstream bacterial infection is greatest with a central venous access device since the tip is placed directly in the superior vena cava. A localized operative site infection or pulmonary infection would be most likely after femoral surgery. Complete bed rest could result in a pulmonary or urinary infection. PICC lines puts a client at risk for phlebitis initially which could progress to bacteremia, would develop over a longer period of time.
Subcategory – Standard precautions/Transmission-based Precautions/Surgical asepsis
Rationale – The possibility of a bloodstream bacterial infection is greatest with a central venous access device since the tip is placed directly in the superior vena cava. A localized operative site infection or pulmonary infection would be most likely after femoral surgery. Complete bed rest could result in a pulmonary or urinary infection. PICC lines puts a client at risk for phlebitis initially which could progress to bacteremia, would develop over a longer period of time.
Subcategory – Standard precautions/Transmission-based Precautions/Surgical asepsis
The nurse is caring for a 6 month-old diagnosed with a contagious illness. The child is on contact precautions. Which of the following toys is most appropriate to suggest to the child’s parent they bring for the child to play with?
Rationale – Plastic blocks can be easily disinfected, more so than a stuffed animal. A toy piano and coloring book are developmentally inappropriate and/or unsafe.
Subcategory – Standard precautions/Transmission-based Precautions/Surgical asepsis
Rationale – Plastic blocks can be easily disinfected, more so than a stuffed animal. A toy piano and coloring book are developmentally inappropriate and/or unsafe.
Subcategory – Standard precautions/Transmission-based Precautions/Surgical asepsis
A nursing instructor overhears a nurse stating her client is about to have a PICC line placement procedure in their room. The nursing instructor asks “Can two students observe the insertion of the PICC line?” Which of the following is the best response by the nurse?
Rationale – Donning masks and standing away from the bedside poses the lowest risk of site exposure to microorganisms and low risk of sterile field contamination. A good observational experience is acceptable response but not the best – it does not address the bigger risk of infection to the client. Masked observers pose no risk to the client. It is incorrect, unless a policy is in place stating, to limit the nurses in the room.
Subcategory – Standard precautions/Transmission-based Precautions/Surgical asepsis
Rationale – Donning masks and standing away from the bedside poses the lowest risk of site exposure to microorganisms and low risk of sterile field contamination. A good observational experience is acceptable response but not the best – it does not address the bigger risk of infection to the client. Masked observers pose no risk to the client. It is incorrect, unless a policy is in place stating, to limit the nurses in the room.
Subcategory – Standard precautions/Transmission-based Precautions/Surgical asepsis
Which of the following is the most appropriate long term goal for the client placed on neutropenic precautions?
Rationale – Neutropenia refers only to a low WBC.
Subcategory – Standard precautions/Transmission-based Precautions/Surgical asepsis
Rationale – Neutropenia refers only to a low WBC.
Subcategory – Standard precautions/Transmission-based Precautions/Surgical asepsis
The nurse is caring for a client with thrombocytopenia. Which of the following will the nurse include in teaching the client about precautions taken for the condition of neutropenia? Select all that apply.
Rationale- Visitors wearing masks, a private room, no fresh flowers, and no consumption of fresh fruits or veggies are actions implemented for clients with neutropenia to prevent infections. Use of an electric shaver and rectal temperatures are precautions against bleeding for the client with thrombocytopenia.
Subcategory – Standard precautions/Transmission-based Precautions/Surgical asepsis
Rationale- Visitors wearing masks, a private room, no fresh flowers, and no consumption of fresh fruits or veggies are actions implemented for clients with neutropenia to prevent infections. Use of an electric shaver and rectal temperatures are precautions against bleeding for the client with thrombocytopenia.
Subcategory – Standard precautions/Transmission-based Precautions/Surgical asepsis
The nurse is caring for a client in the intensive care unit. The healthcare provider has ordered IV hypertensive medications to be initiated. Which initial action by the nurse should be taken?
Rationale – The safety alarms on the automated blood pressure monitor should be set so immediate action for abnormal readings can be addressed. Safety systems on equipment should be used for their intended purpose. The medication route is IV and the effects will be seen sooner than one half hour.
Subcategory – Use of restraints/Safety devices
Rationale – The safety alarms on the automated blood pressure monitor should be set so immediate action for abnormal readings can be addressed. Safety systems on equipment should be used for their intended purpose. The medication route is IV and the effects will be seen sooner than one half hour.
Subcategory – Use of restraints/Safety devices
The nurse recognizes that which of the following requires an incident report in the course of caring for their client?
Rationale – Infiltration with edema at the IV site is an example of an injury to a client resulting from treatment. It is correct to discard voided urine at the beginning of a 24 hour urine sampling. Discarding the last voided urine at conclusion causes no direct client injury. Humalog insulin is an accepted treatment for hyperglycemia.
Subcategory – Use of restraints/Safety devices
Rationale – Infiltration with edema at the IV site is an example of an injury to a client resulting from treatment. It is correct to discard voided urine at the beginning of a 24 hour urine sampling. Discarding the last voided urine at conclusion causes no direct client injury. Humalog insulin is an accepted treatment for hyperglycemia.
Subcategory – Use of restraints/Safety devices
What is a priority concern for a client that is participating in an inpatient rehabilitation program following a total hip replacement?
Rationale – According to Maslow’s hierarchy of needs safety is of the highest priority when compared with the other possible answers.
Subcategory – Safety and Infection Control- Ergonomic Principles
Rationale – According to Maslow’s hierarchy of needs safety is of the highest priority when compared with the other possible answers.
Subcategory – Safety and Infection Control- Ergonomic Principles
What is a priority concern for a client that is participating in an inpatient rehabilitation program following a total hip replacement?
Rationale – According to Maslow’s hierarchy of needs safety is of the highest priority when compared with the other possible answers.
Subcategory – Ergonomic Principles
Rationale – According to Maslow’s hierarchy of needs safety is of the highest priority when compared with the other possible answers.
Subcategory – Ergonomic Principles
A client with a swallowing dysfunction has received teaching regarding interventions to avoid aspiration. What action by the client demonstrates a need for further teaching?
Rationale – Drinking fluid with harder foods will not reduce the risk of aspiration. The client should eat soft foods, sit upright while eating, take smaller bites and took their chin and turn their head while swallowing.
Subcategory – Potential for alterations in body systems
Rationale – Drinking fluid with harder foods will not reduce the risk of aspiration. The client should eat soft foods, sit upright while eating, take smaller bites and took their chin and turn their head while swallowing.
Subcategory – Potential for alterations in body systems
A client that is 10 hours post thoracotomy should have what interventions implemented? Select all that apply.
Rationale – A client that has just undergone a thoracotomy will need to do arm and shoulder exercises, BMB leaving as early as eight hours after surgery and use a pillow to splint. The client should be encouraged to cough and deep breathe. Opiate pain medication is used by PCA pump or IV.
Subcategory – Potential for Complications from Surgical Procedures
Rationale – A client that has just undergone a thoracotomy will need to do arm and shoulder exercises, BMB leaving as early as eight hours after surgery and use a pillow to splint. The client should be encouraged to cough and deep breathe. Opiate pain medication is used by PCA pump or IV.
Subcategory – Potential for Complications from Surgical Procedures
A client admitted to a pediatric unit with cystic fibrosis would benefit from what type of intervention to remove bronchial secretions? Select all that apply.
Rationale – Postural drainage and chest percussion both assist the removal of bronchial secretions. Oral suctioning will not remove bronchial secretions. Pursed lip breathing helps reduce trapped air. Non humidified oxygen will not help with minimizing secretions.
Subcategory – Therapeutic Procedures
Rationale – Postural drainage and chest percussion both assist the removal of bronchial secretions. Oral suctioning will not remove bronchial secretions. Pursed lip breathing helps reduce trapped air. Non humidified oxygen will not help with minimizing secretions.
Subcategory – Therapeutic Procedures
Emergency room nurse is providing discharge instructions to a client that was diagnosed with epistaxis. What statement by the client indicates a need for further teaching?
Rationale – A client should put their index finger and thumb at the bridge of the nose and tilt their head forward not backwards. They should avoid hot and spicy foods. They should not forcefully blow their nose. A client who is had nosebleeds should not participate in vigorous exercise for three days.
Subcategory – Potential for Alterations in Body Systems
Rationale – A client should put their index finger and thumb at the bridge of the nose and tilt their head forward not backwards. They should avoid hot and spicy foods. They should not forcefully blow their nose. A client who is had nosebleeds should not participate in vigorous exercise for three days.
Subcategory – Potential for Alterations in Body Systems
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 – Reduction of Risk- Potential for Alterations in Body Systems
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 – Reduction of Risk- Potential for Alterations in Body Systems
A client suspected of having septic shock that is prescribed metoprolol will likely not have what sign of shock?
Rationale – Metoprolol and other beta blockers will often mask tachycardia and a client with shock. The beta blocker will not mask other symptoms of shock.
Subcategory – Potential for complications of diagnostic tests/treatments/procedures
Rationale – Metoprolol and other beta blockers will often mask tachycardia and a client with shock. The beta blocker will not mask other symptoms of shock.
Subcategory – Potential for complications of diagnostic tests/treatments/procedures
An older adult client is admitted to the hospital with diarrhea. What assessment should receive priority in this client’s care?
Rationale – The urinary output should take priority because it would be an assessment that would determine the client’s hydration status. Dehydration is one of the major complications of diarrhea and decreased urine output would be an indication of dehydration.
Subcategory – Potential for Alterations in body systems
Rationale – The urinary output should take priority because it would be an assessment that would determine the client’s hydration status. Dehydration is one of the major complications of diarrhea and decreased urine output would be an indication of dehydration.
Subcategory – Potential for Alterations in body systems
A client that has undergone a femoral popliteal bypass graft has history of severe intermittent claudication. What intervention by the nurse is most appropriate on day one postop?
Rationale – It is important to assist the client to ambulate as early as possible to decrease the effects of intermittent claudication and other complications of the femoral popliteal bypass graft. The client does not have to stay on bed rest. They do not have to maintain their legs elevated above their heart. It is not necessary to have physical therapy be the only one working with the client on ambulation.
Subcategory – Potential for Complications from Surgical Procedures
Rationale – It is important to assist the client to ambulate as early as possible to decrease the effects of intermittent claudication and other complications of the femoral popliteal bypass graft. The client does not have to stay on bed rest. They do not have to maintain their legs elevated above their heart. It is not necessary to have physical therapy be the only one working with the client on ambulation.
Subcategory – Potential for Complications from Surgical Procedures
A client is admitted to the intensive care unit with a possible bleed in the cerebrum. What neurologic assessments will give the nurse the best indication of the extent of bleeding?
Rationale – The people every reaction will give an early indication of bleeding. Palmar drift would demonstrate weakness on one side or the other. Tongue position is not an early indication of a cerebral bleed. Deep tendon reflex is there not an indication of an early bleed.
Subcategory – System Specific Assessment
Rationale – The people every reaction will give an early indication of bleeding. Palmar drift would demonstrate weakness on one side or the other. Tongue position is not an early indication of a cerebral bleed. Deep tendon reflex is there not an indication of an early bleed.
Subcategory – System Specific Assessment
A client is admitted to the hospital with tetany in his feet. Upon assessment the nurse lightly taps over the facial nerve in front of the ear and the facial muscles contract. What lab finding is consistent with the client’s symptoms?
Rationale – Hypocalcemia is characterized by tetany and a positive Chvostek’s sign. These findings are not consistent with Hypermagnesemia, hypokalemia or hyponatremia.
Subcategory – System Specific Assessments
Rationale – Hypocalcemia is characterized by tetany and a positive Chvostek’s sign. These findings are not consistent with Hypermagnesemia, hypokalemia or hyponatremia.
Subcategory – System Specific Assessments
A client diagnosed with metastatic pancreatic cancer has opted on palliative care only. The client is undergoing radiofrequency ablation. The nurse correctly identifies what rationale for this procedure?
Rationale – Radiofrequency ablation can be used for pain control and clients with metastasis especially to the bones. It does not involve tissue freezing. It will not relieve dysphasia. It does not prevent dyspnea.
Subcategory – Therapeutic Procedures
Rationale – Radiofrequency ablation can be used for pain control and clients with metastasis especially to the bones. It does not involve tissue freezing. It will not relieve dysphasia. It does not prevent dyspnea.
Subcategory – Therapeutic Procedures
What signs and symptoms are consistent with an extravasation during administration of a vesicant drug? Select all that apply.
Rationale – Symptoms of extravasation include burning at the site, resistance to IV flow and absence of blood return. Air in the IV line is also not sign of extravasation. Blood pressure elevation is not an indication of extravasation.
Subcategory – Potential for complications of diagnostic tests/treatments/procedures
Rationale – Symptoms of extravasation include burning at the site, resistance to IV flow and absence of blood return. Air in the IV line is also not sign of extravasation. Blood pressure elevation is not an indication of extravasation.
Subcategory – Potential for complications of diagnostic tests/treatments/procedures
The client is admitted to the hospital with a diagnosis of esophageal cancer. The client is scheduled to go for radiation therapy to the neck. What intervention does a nurse anticipate preparing the client for prior to beginning radiation?
Rationale – A percutaneous endoscopic gastrostomy tube is placed to provide nutrition to the client who is undergoing radiation to the head or neck. Palliative care consult is not necessary and endoscopy would’ve been used as part of the diagnosis of esophageal cancer and is not necessary before the client starts radiation. Placement of a peripherally inserted central catheter will not assist the client with complications of radiation. TPN may be administered through a central line as an option if malabsorption became a problem, but is not generally decided prior to radiation.
Subcategory – Potential Alterations in Body Systems
Rationale – A percutaneous endoscopic gastrostomy tube is placed to provide nutrition to the client who is undergoing radiation to the head or neck. Palliative care consult is not necessary and endoscopy would’ve been used as part of the diagnosis of esophageal cancer and is not necessary before the client starts radiation. Placement of a peripherally inserted central catheter will not assist the client with complications of radiation. TPN may be administered through a central line as an option if malabsorption became a problem, but is not generally decided prior to radiation.
Subcategory – Potential Alterations in Body Systems
The labor and delivery nurse is applying the external fetal monitor and tocotransducer to a laboring woman at full-term. Which of the following steps should the nurse take prior to implementing monitoring? Select all that apply.
Rationale – It is important to obtain maternal pulse prior to monitoring; gel is applied to fetal heart monitor; woman is allowed to move freely while monitors in place, and RN is responsible for repositioning monitors as needed.
Subcategory – Diagnostic Tests
Rationale – It is important to obtain maternal pulse prior to monitoring; gel is applied to fetal heart monitor; woman is allowed to move freely while monitors in place, and RN is responsible for repositioning monitors as needed.
Subcategory – Diagnostic Tests
A newborn is being prepped for early discharge at 24-hours of age. Which of the following assessment findings by the nurse would be concerning and would require further investigation?
Rationale – Yellowish coloring of the face and chest may indicate jaundice and would require blood work for bilirubin levels.
Subcategory- System Specific Assessments
Rationale – Yellowish coloring of the face and chest may indicate jaundice and would require blood work for bilirubin levels.
Subcategory- System Specific Assessments
The nurse is admitting a newborn to the nursery. The infant was born at 38 weeks of gestation with a birth weight of 4700g. The mother is a gestational diabetic with a body mass index (BMI) of 57. The birth was complicated by a 35 second shoulder dystocia and resuscitation of the infant with positive-pressure ventilation for 60 seconds after birth. Apgar scores were 6 at 1 minute and 9 at 5 minutes. The nurse should anticipate and prepare for which of the following assessment findings?
Rationale – GDM mother and LGA baby equals risk for hypoglycemia
Subcategory- System Specific Assessments
Rationale – GDM mother and LGA baby equals risk for hypoglycemia
Subcategory- System Specific Assessments
A nurse working in the community has volunteered to be part of a bioterrorism exposure Point of dispensing (POD) location. The nurse is preparing to administer ciprofloxacin to large groups of people. What type of exposure have the clients likely experienced?
Rationale – Inhaled anthrax is treated with ciprofloxacin.
Subcategory – Potential for alterations in body systems
Rationale – Inhaled anthrax is treated with ciprofloxacin.
Subcategory – Potential for alterations in body systems
A client scheduled to go to the operating room has a new order for cefazolin IV preoperative prophylaxis. After reviewing the client’s chart what allergies should be brought to the prescriber’s attention and this medication held? Select all that apply.
Rationale – Clients with sensitivities to cephalosporins and penicillins should not be given cefazolin.
Subcategory – Potential for complications of diagnostic tests/treatments/procedures
Rationale – Clients with sensitivities to cephalosporins and penicillins should not be given cefazolin.
Subcategory – Potential for complications of diagnostic tests/treatments/procedures
A client with a chest tube is scheduled to have it removed at 1100. What action by the nurse is priority?
Rationale – The priority intervention for the nurses to pre-medicate the client prior to removal of the chest tube. An informed consent needs to be obtained by the physician not the nurse. The physician should explain the procedure to the client not the nurse. A chest x-ray does not need to be obtained prior to the removal.
Subcategory – Potential for Alterations in Body Systems
Rationale – The priority intervention for the nurses to pre-medicate the client prior to removal of the chest tube. An informed consent needs to be obtained by the physician not the nurse. The physician should explain the procedure to the client not the nurse. A chest x-ray does not need to be obtained prior to the removal.
Subcategory – Potential for Alterations in Body Systems
A female client is reporting dizziness and nausea and has the following labs: troponin I 0.50 and potassium 2.5 mEq/L. What action by the nurse is priority?
Rationale – The healthcare provider should be notified of the elevation of the troponin and decrease in the potassium to receive orders. IV potassium cannot be given until an order is received. Repeat labs are not indicated immediately. A stat echocardiogram would not be ordered emergently for this client.
Subcategory – Laboratory Values
Rationale – The healthcare provider should be notified of the elevation of the troponin and decrease in the potassium to receive orders. IV potassium cannot be given until an order is received. Repeat labs are not indicated immediately. A stat echocardiogram would not be ordered emergently for this client.
Subcategory – Laboratory Values
The nurse is been providing teaching about risk factors related to laryngeal cancer to a group of factory workers. What risk factors should the nurse discussed in this teaching? Select all that apply.
Rationale – Risk factors associated with laryngeal cancer include use of tobacco, excess alcohol use and an overuse of the voice. Poor dental hygiene and obesity are not related to laryngeal cancer.
Subcategory – Potential for Alterations in Body Systems
Rationale – Risk factors associated with laryngeal cancer include use of tobacco, excess alcohol use and an overuse of the voice. Poor dental hygiene and obesity are not related to laryngeal cancer.
Subcategory – Potential for Alterations in Body Systems
A client admitted to the hospital for a 24 hour urine collection with a suspected diagnosis of Addison’s disease requires what priority nursing intervention?
Rationale – It is important to get an accurate 24 hour urine collection to keep the client, and reduce stress.
Subcategory – Diagnostic Tests
Rationale – It is important to get an accurate 24 hour urine collection to keep the client, and reduce stress.
Subcategory – Diagnostic Tests
The nurse is preparing to collect a sputum culture from her client. Please the order of obtaining the culture and the sequence the nurse should performance.
Rationale – It is important to check for an order prior to getting the container. Once the container is obtained, the nurse should teach the client how to deep breathe and then have the client forcefully cough into the container. As soon as the specimen is obtained it should be sent directly to the laboratory.
Subcategory – Diagnostic Tests
Rationale – It is important to check for an order prior to getting the container. Once the container is obtained, the nurse should teach the client how to deep breathe and then have the client forcefully cough into the container. As soon as the specimen is obtained it should be sent directly to the laboratory.
Subcategory – Diagnostic Tests
A client with a chest tube inserted attempts to get out of bed alone and disconnects the chest tube from the drainage system. The tubing falls on the floor. What action by the nurse is priority upon entering the room?
Rationale – If the chest tube becomes disconnected the priority intervention by the nurse is to please the tube in sterile water or Saline to prevent air from getting into the chest. After placing the chest tube in water or Saline The nurse would notify the healthcare provider. The nurse should not set up a new chest drainage system until the client has been assessed.
Subcategory – Potential for Complications from Surgical Procedures and Health Alterations
Rationale – If the chest tube becomes disconnected the priority intervention by the nurse is to please the tube in sterile water or Saline to prevent air from getting into the chest. After placing the chest tube in water or Saline The nurse would notify the healthcare provider. The nurse should not set up a new chest drainage system until the client has been assessed.
Subcategory – Potential for Complications from Surgical Procedures and Health Alterations
A client with a tracheostomy placed two weeks ago coughs and the tracheostomy tube comes out. What action by the nurse is priority?
Rationale – The priority intervention when a client’s tracheostomy tube comes out is to place it back in. The nurse should utilize the obturator to reinsert the tracheostomy tube. A nurse should be aware of replacement of a tracheostomy tube and should not need to call for help. Suctioning a stoma for secretions is not priority. Pleasing oxygen over the stoma is not priority, replacing the tracheostomy tube is.
Subcategory – Potential for Alterations in Body Systems
Rationale – The priority intervention when a client’s tracheostomy tube comes out is to place it back in. The nurse should utilize the obturator to reinsert the tracheostomy tube. A nurse should be aware of replacement of a tracheostomy tube and should not need to call for help. Suctioning a stoma for secretions is not priority. Pleasing oxygen over the stoma is not priority, replacing the tracheostomy tube is.
Subcategory – Potential for Alterations in Body Systems
A client is asked to rate their pain on a scale of 0 to 10, zero being no pain and 10 being the worst pain I have ever felt. What characteristic of pain is the nurse assessing?
Rationale – Intensity is measured on a 0 to 10 scale and clients who can report their pain themselves. The 0 to 10 scale does not rate duration, type or location.
Subcategory – System Specific Assessments
Rationale – Intensity is measured on a 0 to 10 scale and clients who can report their pain themselves. The 0 to 10 scale does not rate duration, type or location.
Subcategory – System Specific Assessments
The school nurse has had a child come to the office during lunch time for the past several days. The child appears unkempt and has not had a lunch. What action by the school nurse is priority?
Rationale – A child that has not eaten and appears unkempt has signs of maltreatment and neglect. The nurse should first assess for other signs of abuse. Notifying the principal is not priority. The children’s parents should not be contacted until the child is assessed for other signs and symptoms of abuse. Asking is how when they have last eaten review appropriate after further assessment is obtained.
Subcategory – Abuse/Neglect
Rationale – A child that has not eaten and appears unkempt has signs of maltreatment and neglect. The nurse should first assess for other signs of abuse. Notifying the principal is not priority. The children’s parents should not be contacted until the child is assessed for other signs and symptoms of abuse. Asking is how when they have last eaten review appropriate after further assessment is obtained.
Subcategory – Abuse/Neglect
The nurse is teaching a client about coping strategies after losing a loved one. What statement by the client indicates a need for further teaching?
Rationale – Journaling is an effective way of dealing with loss in a very good coping strategy for those that have lost a loved one. Anger is a normal feeling often associated with loss. Talking about feelings may often help people cope. Focusing on positive emotions may help people deal with loss.
Subcategory – Coping Mechanisms
Rationale – Journaling is an effective way of dealing with loss in a very good coping strategy for those that have lost a loved one. Anger is a normal feeling often associated with loss. Talking about feelings may often help people cope. Focusing on positive emotions may help people deal with loss.
Subcategory – Coping Mechanisms
A client is brought to the emergency department with acute intoxication from Methamphetamines. The nurse should observe the client for what priority side effect of this medication?
Rationale – Violence is a side effect of methamphetamines, placing the client and others at risk for injury. Lethargy is not a side effect of methamphetamines. Vomiting and G.I. bleeding are not priority side effects when a client is brought in for acute intoxication.
Subcategory – Chemical and other Dependencies/Substance Use Disorders
Rationale – Violence is a side effect of methamphetamines, placing the client and others at risk for injury. Lethargy is not a side effect of methamphetamines. Vomiting and G.I. bleeding are not priority side effects when a client is brought in for acute intoxication.
Subcategory – Chemical and other Dependencies/Substance Use Disorders
The client has made it to the hospital with a diagnosis of anxiety related to a situational crisis. What goal is priority for this client?
Rationale – The priority for this client is that they remain free from harm. Long-term goals would include the client returning to their pre-crisis state. It is important for them to verbalize their thoughts and feelings related to the event and to explore alternative solutions for coping however remaining free from harm is the most important goal.
Subcategory – Crisis Intervention
Rationale – The priority for this client is that they remain free from harm. Long-term goals would include the client returning to their pre-crisis state. It is important for them to verbalize their thoughts and feelings related to the event and to explore alternative solutions for coping however remaining free from harm is the most important goal.
Subcategory – Crisis Intervention
The nurse is caring for a kosher Jewish client. What food should be sent back and a new tray requested?
Rationale – Kosher Jewish clients are not able to eat pork products. Vegetarian lasagna is an acceptable selection. Cereal and a banana are appropriate. Chicken and broccoli with Alfredo is not contraindicated with kosher Jewish clients.
Subcategory – Cultural Awareness
Rationale – Kosher Jewish clients are not able to eat pork products. Vegetarian lasagna is an acceptable selection. Cereal and a banana are appropriate. Chicken and broccoli with Alfredo is not contraindicated with kosher Jewish clients.
Subcategory – Cultural Awareness
The nurse is holding a support group for several clients diagnosed with personality disorders. After selecting the group leader one of the client’s gets angry and asks the nurse why they chose that client as a leader. What statement by the nurse demonstrates a therapeutic, assertive approach?
Rationale – It is important for the nurse to respond to the question, however be assertive in their answer. The other responses are non-therapeutic and do not address the situation.
Subcategory – Mental Health Concepts
Rationale – It is important for the nurse to respond to the question, however be assertive in their answer. The other responses are non-therapeutic and do not address the situation.
Subcategory – Mental Health Concepts
When caring for clients with diverse religious and spiritual backgrounds, what action by the nurse is priority?
Rationale – It is important for nurses to understand their own beliefs when learning how to understand spirituality and religion with their own clients. It is not necessary to understand all other religions. Sharing their faith and beliefs is not appropriate. Avoiding spiritual religious situations deemed uncomfortable is not the best approach.
Subcategory – Psychosocial Integrity
Rationale – It is important for nurses to understand their own beliefs when learning how to understand spirituality and religion with their own clients. It is not necessary to understand all other religions. Sharing their faith and beliefs is not appropriate. Avoiding spiritual religious situations deemed uncomfortable is not the best approach.
Subcategory – Psychosocial Integrity
The nurses providing teaching to a nursing student regarding Islamic faith. What statement by the student indicates a need for further teaching?
Rationale – Islamic family members do not often have issue with taking their loved ones off of life support. Islamic followers also often avoid discussing death. These clients often do not allow organ transplantation or donation. Muslims do not eat until the sun goes down during the month of Ramadan.
Subcategory – Cultural Awareness/Cultural Influences on Health
Rationale – Islamic family members do not often have issue with taking their loved ones off of life support. Islamic followers also often avoid discussing death. These clients often do not allow organ transplantation or donation. Muslims do not eat until the sun goes down during the month of Ramadan.
Subcategory – Cultural Awareness/Cultural Influences on Health
What action by the nurse is most appropriate after the death of a Hindu client?
Rationale – Hindu faith requires the body to be placed with the head facing north. Closing the eyes and mouth is Islamic faith. The body is often cremated so burial would not occur immediately. Rosary beads are often seen in Hispanic and Latino culture.
Subcategory – Cultural Awareness/Cultural influences on health
Rationale – Hindu faith requires the body to be placed with the head facing north. Closing the eyes and mouth is Islamic faith. The body is often cremated so burial would not occur immediately. Rosary beads are often seen in Hispanic and Latino culture.
Subcategory – Cultural Awareness/Cultural influences on health
When determining effective methods of stress reduction, the nurse evaluates unpredictable events that can occur anytime in the lifespan as what type of stressors?
Rational – Situational stressors are unpredictable and may occur at any time in the lifespan. Chemical stressors are related to toxic substances. Psychological stressors arise events in response to a primary or secondary structure. Developmental are associated with predictable events.
Subcategory – Coping Mechanisms
Rational – Situational stressors are unpredictable and may occur at any time in the lifespan. Chemical stressors are related to toxic substances. Psychological stressors arise events in response to a primary or secondary structure. Developmental are associated with predictable events.
Subcategory – Coping Mechanisms
A client recently diagnosed with dilated cardiomyopathy has decided focus on spiritual needs and quality of life. Without aggressive treatment the client is expected to live another 2 to 4 years. What type of care will this client likely receive?
Rationale – Palliative care focuses on supporting comfort and quality of life. Hospice is used when death is much closer than 2 to 4 years. A client with dilated cardiomyopathy would not be able to have restorative or rehabilitative therapy.
Subcategory – End of Life Care
Rationale – Palliative care focuses on supporting comfort and quality of life. Hospice is used when death is much closer than 2 to 4 years. A client with dilated cardiomyopathy would not be able to have restorative or rehabilitative therapy.
Subcategory – End of Life Care
The nurse is caring for a Hindu client who has requested a bath. What action by the nurse demonstrates cultural awareness? Select all that apply.
Rationale – Hindu clients prefer a caregiver of the same sex, they prefer bathing with free flowing water and praying after bathing. Tepid water does not have to be used. Family members do not need to assist with bathing.
Subcategory – Religious and Spiritual Influences on Health
Rationale – Hindu clients prefer a caregiver of the same sex, they prefer bathing with free flowing water and praying after bathing. Tepid water does not have to be used. Family members do not need to assist with bathing.
Subcategory – Religious and Spiritual Influences on Health
A client admitted for dehydration with history of dementia has been found attempting to leave through the fire escape door. What statement by the nurse is most therapeutic?
Rationale– It is important to read orient the client and get them to a safe place. Questioning what they are doing and what they’re looking for will not help to reorient them. Telling them they shouldn’t be in the hallway alone is not therapeutic.
Subcategory- Therapeutic Communication
Rationale– It is important to read orient the client and get them to a safe place. Questioning what they are doing and what they’re looking for will not help to reorient them. Telling them they shouldn’t be in the hallway alone is not therapeutic.
Subcategory- Therapeutic Communication
A client diagnosed with social isolation has been refusing group therapy. What intervention by the nurse is most appropriate?
Rationale – It is important if a client with social isolation is refusing group therapy to still include them in some contact with other people. One to one contact is a good way to start and gradually increase to a group based therapy. Medication should not be administered. You cannot make the clients attend. Having a client remain in the room will not improve their functioning or therapy.
Subcategory- Mental health concepts
Rationale – It is important if a client with social isolation is refusing group therapy to still include them in some contact with other people. One to one contact is a good way to start and gradually increase to a group based therapy. Medication should not be administered. You cannot make the clients attend. Having a client remain in the room will not improve their functioning or therapy.
Subcategory- Mental health concepts
When caring for a client with acute confusion which action by the nurse is most appropriate? Select all that apply.
Rationale – It is important to include the client in their own care. Playing soft music during care may relax the client. Encouraging the client to discuss a topic of interest may help them focus. Step-by-step directions will help the client focus. Visitors do not have to be limited to two hours a day.
Subcategory- Mental health concepts
Rationale – It is important to include the client in their own care. Playing soft music during care may relax the client. Encouraging the client to discuss a topic of interest may help them focus. Step-by-step directions will help the client focus. Visitors do not have to be limited to two hours a day.
Subcategory- Mental health concepts
What treatments are priority for a client diagnosed with neuroleptic malignant syndrome after beginning an antipsychotic medication? Select all that apply.
Rationale – Clients with neuroleptic malignant syndrome should have the medication discontinued, be adequately hydrated and heparin is administered to prevent clotting. Avoiding antipyretic therapy is not indicated as the client will need antipyretic therapy. Applying warm compresses is contraindicated.
Subcategory- Mental health concepts
Rationale – Clients with neuroleptic malignant syndrome should have the medication discontinued, be adequately hydrated and heparin is administered to prevent clotting. Avoiding antipyretic therapy is not indicated as the client will need antipyretic therapy. Applying warm compresses is contraindicated.
Subcategory- Mental health concepts
A client was just told by their primary provider that the results of the lung biopsy were positive for Stage 4. What action by the nurse is most appropriate?
Rationale – It is important to allow the client time to express concerns after receiving a new diagnosis. Leaving the room will not allow them time to express concerns or as questions. Providing literature may be appropriate after the client has had time to ask questions and express concerns. Offering medication may be indicated after the client has had the chance to express concerns and ask questions.
Subcategory – Grief and Loss
Rationale – It is important to allow the client time to express concerns after receiving a new diagnosis. Leaving the room will not allow them time to express concerns or as questions. Providing literature may be appropriate after the client has had time to ask questions and express concerns. Offering medication may be indicated after the client has had the chance to express concerns and ask questions.
Subcategory – Grief and Loss
What stage of grief is a client experiencing if they state, “No, it can’t be true that my husband has died”?
Rationale- Shock and disbelief occurs in the initial stages of loss. The family and loved ones often are shocked and do not fully recognize the loss.
Subcategory – Grief and Loss
Rationale- Shock and disbelief occurs in the initial stages of loss. The family and loved ones often are shocked and do not fully recognize the loss.
Subcategory – Grief and Loss
An elderly client has just expressed that “I know I am going to die.” The nurse is aware of what tasks that the dying person will face? Select all that apply.
Rationale- A dying person must review family and life relationships, realize they will be going from known to unknown and cope with the physical symptoms they will experience. Denial is not a task that is productive once death is accepted. The decision to die alone in the hospital is not a functional decision if the client has accepted death is going to occur.
Subcategory – Grief and Loss
Rationale- A dying person must review family and life relationships, realize they will be going from known to unknown and cope with the physical symptoms they will experience. Denial is not a task that is productive once death is accepted. The decision to die alone in the hospital is not a functional decision if the client has accepted death is going to occur.
Subcategory – Grief and Loss
A 16 year-old client presents to the prenatal clinic and is diagnosed with an intrauterine pregnancy at 8 weeks gestation. She presents to the Emergency Department (ED) two weeks later with abdominal pain and heavy bleeding. When the ED provider informs the client she is miscarrying, the woman begins crying and screams “Why am I being punished? I was going to keep the baby! This isn’t fair!” Which of the following is the most appropriate nursing response?
Rationale – Acknowledges the client’s loss and lets her know you care about her. The other responses attempt to make her feel better without acknowledging the current situation.
Subcategory- Therapeutic Communication
Rationale – Acknowledges the client’s loss and lets her know you care about her. The other responses attempt to make her feel better without acknowledging the current situation.
Subcategory- Therapeutic Communication
When assisting a client in the hospital to maintain a sense of self what is an appropriate strategy to use?
Rationale – Treating clients with dignity and respect is a fundamental aspect in the nurse-client relationship in order to assist open communication. Using a client’s nickname may be helpful but only when a client rants permission. An explanation for every procedure should be a routine part of care. Personal belongings may help a client to be more comfortable.
Subcategory- Coping Mechanisms
Rationale – Treating clients with dignity and respect is a fundamental aspect in the nurse-client relationship in order to assist open communication. Using a client’s nickname may be helpful but only when a client rants permission. An explanation for every procedure should be a routine part of care. Personal belongings may help a client to be more comfortable.
Subcategory- Coping Mechanisms
An adolescent client is hospitalized following a sports accident for a fractured femur and is in traction. It is encouraged that the client be allowed his/her high school friends to visit. This will aid in meeting the needs of what dimension of health?
Rationale – During the adolescent stage it is important for them to establish relationships with peers independently from their parents/caregivers. It allows them to define their role in society and build a framework for the future.
Subcategory- Coping Mechanisms
Rationale – During the adolescent stage it is important for them to establish relationships with peers independently from their parents/caregivers. It allows them to define their role in society and build a framework for the future.
Subcategory- Coping Mechanisms
A client that has been admitted to the hospital with end stage renal disease has been observed to have poor eye contact, an unkempt appearance, and a poor appetite. This data supports what potential problem?
Rationale – Some of the most common signs of depression may be poor eye contact and a patient’s lack of interest in personal appearance. A decrease in appetite may be due to depression or it could be a result of disease progression.
Subcategory- Mental Health Concepts
Rationale – Some of the most common signs of depression may be poor eye contact and a patient’s lack of interest in personal appearance. A decrease in appetite may be due to depression or it could be a result of disease progression.
Subcategory- Mental Health Concepts
A male nurse is attempting to provide care for an older adult female client. When he approaches her she turns away and draws the blankets up to her neck. What would be the next best appropriate action?
Rationale – The reason for the client’s behavior is unknown, therefore a discussion should be open to find out why the client is withdrawn. Explaining the procedure then requesting permission to continue may reduce the client’s anxiety and may allow the nurse to continue with providing care.
Subcategory- Therapeutic Communication
Rationale – The reason for the client’s behavior is unknown, therefore a discussion should be open to find out why the client is withdrawn. Explaining the procedure then requesting permission to continue may reduce the client’s anxiety and may allow the nurse to continue with providing care.
Subcategory- Therapeutic Communication
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- Crisis Intervention
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- Crisis Intervention
What nursing behaviors are necessary according to Leininger’s Theory of transcultural caring? Select all that apply.
Rationale – According to Leininger’s theory of transcultural caring the nurse should know the client’s cultural norms, have an understanding of the client’s cultural practices regarding end-of-life and have an awareness of words or gestures that have various meanings. Being aware of your own cultural feelings and beliefs is important however it is not part of this theory. Avoiding discussing cultural practices with clients will not help you care for the client.
Subcategory – Cultural Awareness/Cultural Influences on Health
Rationale – According to Leininger’s theory of transcultural caring the nurse should know the client’s cultural norms, have an understanding of the client’s cultural practices regarding end-of-life and have an awareness of words or gestures that have various meanings. Being aware of your own cultural feelings and beliefs is important however it is not part of this theory. Avoiding discussing cultural practices with clients will not help you care for the client.
Subcategory – Cultural Awareness/Cultural Influences on Health
The nurse enters the room of an older adult client that has just been admitted to the unit. The client asked the nurse why she is in her home. She has her sheets and blanket on the floor her shoes on and a sweater over her down. The IV line that had been placed is on the ground in there is blood noted at the client’s antecubital area. The nurse’s observations are an example of what type of critical thinking skills?
Rationale – The nurse is categorizing and collecting data which is part of the interpretation skill of critical thinking. Analysis would be putting the data together. The nurse would then determine the significance of the findings and key relationships. The evaluation involves determining results of any actions. Explanation would be supporting findings and selecting strategies to use in the care of the client.
Subcategory – Therapeutic Environment
Rationale – The nurse is categorizing and collecting data which is part of the interpretation skill of critical thinking. Analysis would be putting the data together. The nurse would then determine the significance of the findings and key relationships. The evaluation involves determining results of any actions. Explanation would be supporting findings and selecting strategies to use in the care of the client.
Subcategory – Therapeutic Environment
Which of the following nursing actions demonstrates the concept of client advocacy?
Rationale– Nurses advocate for and educate the public about issues that promote and protect the health of the public.
Subcategory- Advocacy
Rationale– Nurses advocate for and educate the public about issues that promote and protect the health of the public.
Subcategory- Advocacy
The nurse is caring for a middle-aged client who had a total hip arthroplasty 5 days ago. The discharge plan is for transfer to a rehabilitation facility for gait training and strengthening. The client wishes to go home. What is the nurse’s best action?
Rationale– Exploring the abilities of the client in relation to their health and safety needs is the priority –it addresses the client’s concern and helps the client understand his needs in making an informed decision about his rehabilitation. Once this is completed, if the client is steadfast in their desire, the other options can be executed.
Subcategory- Advocacy
Rationale– Exploring the abilities of the client in relation to their health and safety needs is the priority –it addresses the client’s concern and helps the client understand his needs in making an informed decision about his rehabilitation. Once this is completed, if the client is steadfast in their desire, the other options can be executed.
Subcategory- Advocacy
A nursing student has just completed administering an analgesic medication to an adult client for complaints of abdominal pain. What information will the instructor expect to find in the medical record as documentation of this intervention by the student nurse? Select all that apply.
Rationale– All are components of analgesic medication administration documentation. General location of pain needs to be document with the specific location of pain. For medication safety, the healthcare provider’s ordered interval for the analgesic would have been verified prior to administering the analgesic. Follow-up documentation cannot be completed at this time – it occurs at a later time, dictated by the route administered and expected onset of medication.
Subcategory- Assignment, Delegation, Supervision
Rationale– All are components of analgesic medication administration documentation. General location of pain needs to be document with the specific location of pain. For medication safety, the healthcare provider’s ordered interval for the analgesic would have been verified prior to administering the analgesic. Follow-up documentation cannot be completed at this time – it occurs at a later time, dictated by the route administered and expected onset of medication.
Subcategory- Assignment, Delegation, Supervision
The nurse is caring for a client recovering from a gunshot wound to the face. Which of the following tasks can be assigned to the UAP working with the nurse?
Rationale– Only task not requiring a nurse to implement in this scenario is obtaining a daily weight for the client. Since the client’s injury is to the face, UAP implementation would be incorrect assigning of tasks. Monitoring and facilitating therapeutic communication regarding body image is the responsibility of the nurse.
Subcategory- Assignment, Delegation, Supervision
Rationale– Only task not requiring a nurse to implement in this scenario is obtaining a daily weight for the client. Since the client’s injury is to the face, UAP implementation would be incorrect assigning of tasks. Monitoring and facilitating therapeutic communication regarding body image is the responsibility of the nurse.
Subcategory- Assignment, Delegation, Supervision
A nurse has admitted a famous movie actor to the psychiatric unit with a diagnosis of suicidal ideations. Another nurse on the unit asks, “Why was he admitted?” The nurse’s best response is which of the following?
Rationale– Unless the other nurse is involved in this client’s care, they have no legal right to know this information. Revealing this information to another nurse not caring for this client is a violation of the client’s privacy and the HIPPA law. All other responses are not appropriate.
Subcategory- Confidentiality/Information Security
Rationale– Unless the other nurse is involved in this client’s care, they have no legal right to know this information. Revealing this information to another nurse not caring for this client is a violation of the client’s privacy and the HIPPA law. All other responses are not appropriate.
Subcategory- Confidentiality/Information Security
A nurse is functioning as a case manager at a mental health care organization. What is the nurse’s most important role in this position?
Rationale- As a case manager, coordination of services is a primary job function.
Subcategory- Continuity of Care
Rationale- As a case manager, coordination of services is a primary job function.
Subcategory- Continuity of Care
A client has returned from arthroscopic knee surgery under local nerve block analgesia six hours ago. The client asks to go to the bathroom. What is the nurse’s next best action?
Rationale– This assessment would reveal any neurovascular deficits remaining from the nerve block that would compromise safe client ambulation. All other options are valid options once it is determined that neurovascular findings noted will not affect safe ambulation.
Subcategory- Establishing Priorities
Rationale– This assessment would reveal any neurovascular deficits remaining from the nerve block that would compromise safe client ambulation. All other options are valid options once it is determined that neurovascular findings noted will not affect safe ambulation.
Subcategory- Establishing Priorities
The nurse is caring for a client who is morbidly obese and has a diagnosis of diabetes mellitus. The client had open abdominal surgery for lysis of adhesions two days ago. The client reports vomiting and abdominal pain. What is the nurse’s priority action?
Rationale-– The client’s history puts them at risk for wound dehiscence warranting immediate wound assessment. Other options are viable in this situation but would occur after the wound assessment.
Subcategory- Establishing Priorities
Rationale-– The client’s history puts them at risk for wound dehiscence warranting immediate wound assessment. Other options are viable in this situation but would occur after the wound assessment.
Subcategory- Establishing Priorities
A nurse in the Emergency Department is informed a client in the third trimester of pregnancy with severe uterine bleeding is being transported to the hospital. Upon the client arrival, what is the nurse’s priority action?
Rationale– Fluid replacement is the priority with severe bleeding to replace lost fluid volume. All other options are appropriate in this situation but are not the most important in rescue of this client.
Subcategory- Establishing Priorities
Rationale– Fluid replacement is the priority with severe bleeding to replace lost fluid volume. All other options are appropriate in this situation but are not the most important in rescue of this client.
Subcategory- Establishing Priorities
Which of the following is a component of the client electronic medical record that serves as a direct client safety strategy?
Rationale– Provides clear orders without the possibility of misinterpretation of physician handwriting. Standardized forms, system alerts to required documentation, and automatic log off are not directly related to client safety.
Subcategory- Information Technology
Rationale– Provides clear orders without the possibility of misinterpretation of physician handwriting. Standardized forms, system alerts to required documentation, and automatic log off are not directly related to client safety.
Subcategory- Information Technology
A client having a “do not resuscitate” order from the healthcare provider is discovered by the nurse to be without respirations. What is the nurse’s next action?
Rationale– The nurse must first confirm the client has no pulse or respirations to confirm death has occurred prior to any notifications.
Subcategory- Advanced Directives
Rationale– The nurse must first confirm the client has no pulse or respirations to confirm death has occurred prior to any notifications.
Subcategory- Advanced Directives
A nursing student has completed a lecture on the topic of ethics in nursing. Which of the following does the student recognize as being the cause of ethical dilemmas?
Rationale – When choices for the client are not clearly right or wrong this results in an ethical dilemma. A legal violation is a violation of the ethical principle of nonmaleficence and a deterioration of condition is an emergent situation requiring rapid action for client rescue.
Subcategory- Ethical Practice
Rationale – When choices for the client are not clearly right or wrong this results in an ethical dilemma. A legal violation is a violation of the ethical principle of nonmaleficence and a deterioration of condition is an emergent situation requiring rapid action for client rescue.
Subcategory- Ethical Practice
The parents of a newborn have been informed their child requires surgery and has a poor prognosis for survival. The parents ask the nurse, “what should we do?” Which of the following is the nurse’s best response?
Rationale– The parents are faced with an ethical dilemma and looking at what a reasonable course of action is is the first step in solving an ethical dilemma.
Subcategory- Ethical Practice
Rationale– The parents are faced with an ethical dilemma and looking at what a reasonable course of action is is the first step in solving an ethical dilemma.
Subcategory- Ethical Practice
When caring for clients, the nurse adheres to professional ethical guidelines. What document provides professional ethical guidelines for nurses?
Rationale– Guidelines for ideal professional conduct have been outlined by the American Nurses Association.
Subcategory- Legal Rights and Responsibilities
Rationale– Guidelines for ideal professional conduct have been outlined by the American Nurses Association.
Subcategory- Legal Rights and Responsibilities
A student nurse hears a nurse describe one of their clients as a “crabby old lady,” the student recognizes the nurse is demonstrating which of the following ethical dilemmas?
Rationale– This comment characterizes a stereotype of older aged females. HIPAA is a set of guidelines for protection of health information. Code of Ethics is a general professional ethical guideline. The ethical principle to avoid causing suffering or injury.
Subcategory- Legal Rights and Responsibilities
Rationale– This comment characterizes a stereotype of older aged females. HIPAA is a set of guidelines for protection of health information. Code of Ethics is a general professional ethical guideline. The ethical principle to avoid causing suffering or injury.
Subcategory- Legal Rights and Responsibilities
In addition to the Joint Commission on Accreditation of Healthcare Organizations, the student nurse recognizes what other government agency to provide for government funding of hospitals and penalties for not following guidelines?
Rationale – The American with Disabilities Act protects the civil right of both hospital clients and hospital staff. Failure to adhere to this legal guideline can result in loss of hospital funding and eligibility for low-income loans and financial reimbursements. ANA is a set of guidelines for professional practice, it provides for no government funding. The state that the nurse is practicing in has guidelines for the legal practice of nursing. State Board of Nursing though penalties exist for not adhering to this law, there is no provision for hospital funding.
Subcategory- Legal Rights and Responsibilities
Rationale – The American with Disabilities Act protects the civil right of both hospital clients and hospital staff. Failure to adhere to this legal guideline can result in loss of hospital funding and eligibility for low-income loans and financial reimbursements. ANA is a set of guidelines for professional practice, it provides for no government funding. The state that the nurse is practicing in has guidelines for the legal practice of nursing. State Board of Nursing though penalties exist for not adhering to this law, there is no provision for hospital funding.
Subcategory- Legal Rights and Responsibilities
A student nurse hears a UAP tell a client, “You better start eating or we’ll put that tube down your throat.” The UAP has committed which of the following crimes?
Rationale– Assault is the threat of violence. Battery is physical violence. Negligence is failure to exercise care that a reasonably prudent person would exercise in a similar situation. Malpractice is when an instance of negligence or incompetence on the part of a professional causes harm.
Subcategory- Legal Rights and Responsibilities
Rationale– Assault is the threat of violence. Battery is physical violence. Negligence is failure to exercise care that a reasonably prudent person would exercise in a similar situation. Malpractice is when an instance of negligence or incompetence on the part of a professional causes harm.
Subcategory- Legal Rights and Responsibilities
Which of the following actions does the nurse recognize as being a common trigger for client lawsuits surrounding a hospitalization?
Rationale– The nurse is the final gate-keeper of safety and must assure that all healthcare provider orders are safe to implement for their clients. Nurses’ are accountable for assuring continued nursing care for their clients when they leave the nursing unit. The nurse reports off to the nurse providing care for the client in their absence. Notifying the client of the nurse’s intent to leave the nursing unit for a period of time is a courtesy. Documenting that the healthcare provider ordered the wrong drug is inappropriate but will remain out of legal view unless harm (physical or psychological) comes to the client as a result of this. With client consent, a group of student nurses can observe medical treatments performed. In a teaching hospital the right to have students participate in client care is outlined in the general consent for care.
Subcategory- Legal Rights and Responsibilities
Rationale– The nurse is the final gate-keeper of safety and must assure that all healthcare provider orders are safe to implement for their clients. Nurses’ are accountable for assuring continued nursing care for their clients when they leave the nursing unit. The nurse reports off to the nurse providing care for the client in their absence. Notifying the client of the nurse’s intent to leave the nursing unit for a period of time is a courtesy. Documenting that the healthcare provider ordered the wrong drug is inappropriate but will remain out of legal view unless harm (physical or psychological) comes to the client as a result of this. With client consent, a group of student nurses can observe medical treatments performed. In a teaching hospital the right to have students participate in client care is outlined in the general consent for care.
Subcategory- Legal Rights and Responsibilities
A student nurse has secured a job as a nursing assistant in a hospital. Which statement to the student’s instructor about their new job indicates a lack of understanding as to their scope of practice as a nursing assistant?
Rationale– A nursing student cannot perform professional nursing tasks in a hospital unless functioning on a nursing unit as a nursing student with instructors present.
Subcategory- Legal Rights and Responsibilities
Rationale– A nursing student cannot perform professional nursing tasks in a hospital unless functioning on a nursing unit as a nursing student with instructors present.
Subcategory- Legal Rights and Responsibilities
A nurse has been given an assignment that they believe to be unsafe because of the high acuity of the clients. The nurse manager states, “We have to manage with the staff we have. Two of our nurses’ are out sick today and there is no other staff available in the hospital to help our unit.” What is the nurse’s next action?
Rationale– Writing a memo will provide legal documentation of unsafe staffing should client harm result from staffing level. Clients should not be burdened with staffing issues that can cause undue distress so there is no need to explain the staffing with the client. Not all hospital nurses are represented by a collective bargaining unit. Leaving the unit is considered client abandonment.
Subcategory – Performance Improvement (Quality Improvement)
Rationale– Writing a memo will provide legal documentation of unsafe staffing should client harm result from staffing level. Clients should not be burdened with staffing issues that can cause undue distress so there is no need to explain the staffing with the client. Not all hospital nurses are represented by a collective bargaining unit. Leaving the unit is considered client abandonment.
Subcategory – Performance Improvement (Quality Improvement)
A client asks the nurse, “What is a healthcare proxy?” Which of the following is the nurse’s best response?
Rationale– A person that makes health care decision if you cannot is the best description of a healthcare proxy. The document that determines who receives your possessions when you die is a last will and testament. A living will states your wishes for treatment in the event you can’t make those decisions. Stating your wishes for care is a living will.
Subcategory- Advanced Directives
Rationale– A person that makes health care decision if you cannot is the best description of a healthcare proxy. The document that determines who receives your possessions when you die is a last will and testament. A living will states your wishes for treatment in the event you can’t make those decisions. Stating your wishes for care is a living will.
Subcategory- Advanced Directives
A nurse explains a client’s wishes for end of life care to the client’s family. What role is the nurse demonstrating by this action?
Rationale– An advocate expresses and defends the cause of another. A leader influences others to work together toward a common goal. Caregiver is someone who gives help and protection. A case manager is a person who assists in the planning, coordination, monitoring, and evaluation of medical services for a client with emphasis on quality of care, continuity of services, and cost-effectiveness.
Subcategory-Advocacy
Rationale– An advocate expresses and defends the cause of another. A leader influences others to work together toward a common goal. Caregiver is someone who gives help and protection. A case manager is a person who assists in the planning, coordination, monitoring, and evaluation of medical services for a client with emphasis on quality of care, continuity of services, and cost-effectiveness.
Subcategory-Advocacy
The nurse is supervising the care of clients by a UAP. Which of the following observed action by the UAP would require intervention by the nurse?
Rationale – Leaving a client room with gloves on is a violation of infection control guidelines. Assisting a weak client to the bathroom, feeding a patient who is sitting up in bed, and performing passive range of motion are all appropriate actions by the UAP.
Subcategory- Assignment, Delegation, Supervision
Rationale – Leaving a client room with gloves on is a violation of infection control guidelines. Assisting a weak client to the bathroom, feeding a patient who is sitting up in bed, and performing passive range of motion are all appropriate actions by the UAP.
Subcategory- Assignment, Delegation, Supervision
The nurse is planning for a client to be transferred to their unit from the Emergency Department. The client was admitted with status asthmaticus. What equipment will the nurse assemble in preparation of the client arrival to their unit? Select all that apply.
Rationale– The nurse’s priority is to prevent client harm. Hypoxia, aspiration and mechanical injury from seizure activity are potentially harmful to the client. IV normal saline must be ordered by the healthcare provider. Padded tongue blade is to be placed in a client’s mouth during a seizure.
Subcategory- Case Management
Rationale– The nurse’s priority is to prevent client harm. Hypoxia, aspiration and mechanical injury from seizure activity are potentially harmful to the client. IV normal saline must be ordered by the healthcare provider. Padded tongue blade is to be placed in a client’s mouth during a seizure.
Subcategory- Case Management
A child is brought to the Emergency Department by ambulance with their parent. The child experienced 3 seizures after complaining of neck pain. A lumbar puncture is planned. What is the priority action for the nurse?
Rationale– Legal consent must be obtained prior to the procedure. Gathering equipment is not the priority action. The healthcare provider is accountable for explaining the procedure. IV access would have been established by emergency medical personnel before the child arrived at the hospital.
Subcategory-Client Rights
Rationale– Legal consent must be obtained prior to the procedure. Gathering equipment is not the priority action. The healthcare provider is accountable for explaining the procedure. IV access would have been established by emergency medical personnel before the child arrived at the hospital.
Subcategory-Client Rights
The nurse recognizes their responsibility for ensuring that client rights are not violated. What are client rights? Select all that apply.
Rationale– Determining the healthcare provider, who should make healthcare decisions, and discussion of medical condition including benefit and risks are components of the patient bill of rights. Consenting to a variety of case managers during hospitalization is avoided in an effort to have continuity of care. Information regarding the financial impact of the entire treatment plan is ensured.
Subcategory-Client Rights
Rationale– Determining the healthcare provider, who should make healthcare decisions, and discussion of medical condition including benefit and risks are components of the patient bill of rights. Consenting to a variety of case managers during hospitalization is avoided in an effort to have continuity of care. Information regarding the financial impact of the entire treatment plan is ensured.
Subcategory-Client Rights
Which of the following concepts does the nurse recognize as management concepts? Select all that apply.
Rationale – Leading, budgeting, and organizing are all management concepts. Nursing process is a problem solving process utilized in client care. Quality assurance is a focus on processes to guide client care and improvement of these processes.
Subcategory-Concepts of Management
Rationale – Leading, budgeting, and organizing are all management concepts. Nursing process is a problem solving process utilized in client care. Quality assurance is a focus on processes to guide client care and improvement of these processes.
Subcategory-Concepts of Management
The nurse is admitting an elderly client for sub-acute rehabilitation to a long term care nursing facility. The client experienced a myocardial infarction and now is severely deconditioned. Which statement by the client indicates they are aware of the limitations of Medicare payment for the cost of their care?
Rationale – Medicare will pay the cost of rehabilitation services for elderly clients in a long term care facility from 30-90 days after an acute illness as long as improvement in their condition is demonstrated and documented. All other options are incorrect.
Subcategory – Client Rights
Rationale – Medicare will pay the cost of rehabilitation services for elderly clients in a long term care facility from 30-90 days after an acute illness as long as improvement in their condition is demonstrated and documented. All other options are incorrect.
Subcategory – Client Rights
The nurse in a rehabilitation facility arranges for a discharge planning meeting for a client recovering from a cerebral vascular accident (CVA.) The nurse notifies the Physical Therapy, Occupational Therapy, Speech Therapy, and Nutrition Therapy departments. What professional nurse competency is the nurse demonstrating?
Rationale – Interdisciplinary collaboration is the collaboration of multiple disciplines to coordinate client care. Quality assurance is an ongoing, systematic process to evaluate client care and promote excellence in client care. Continuity of care is the coordination of healthcare services by healthcare providers for clients moving from one healthcare site to another. Client centered care is client care with considerations for their preferences.
Subcategory – Collaboration with Interdisciplinary Team
Rationale – Interdisciplinary collaboration is the collaboration of multiple disciplines to coordinate client care. Quality assurance is an ongoing, systematic process to evaluate client care and promote excellence in client care. Continuity of care is the coordination of healthcare services by healthcare providers for clients moving from one healthcare site to another. Client centered care is client care with considerations for their preferences.
Subcategory – Collaboration with Interdisciplinary Team
Which of the following client situations would require the nurse to request a referral to a Registered Dietician from the health care provider?
Rationale – An adolescent is challenged by their developmental tasks at this age. The need to establish relationships with peers is important. Dietary habits prevalent in this age group (snacking, fast food) and peer pressure regarding alcohol consumption are choices that have potentially severe consequences for the adolescent with a new diagnosis of DM. The client that is day one postoperative nutrition has orders that are followed through by nursing staff as the client’s diet is typically rapidly progressed to a regular diet. The client with colostomy reversal has prior experience in dietary modifications related to bowel surgery. The nursing staff can reinforce specific diets ordered for this client. The client with exacerbation of CHF has had recurrent hospitalizations for this and will only require reinforcement of dietary requirements by the nurse.
Subcategory – Establishing Priorities
Rationale – An adolescent is challenged by their developmental tasks at this age. The need to establish relationships with peers is important. Dietary habits prevalent in this age group (snacking, fast food) and peer pressure regarding alcohol consumption are choices that have potentially severe consequences for the adolescent with a new diagnosis of DM. The client that is day one postoperative nutrition has orders that are followed through by nursing staff as the client’s diet is typically rapidly progressed to a regular diet. The client with colostomy reversal has prior experience in dietary modifications related to bowel surgery. The nursing staff can reinforce specific diets ordered for this client. The client with exacerbation of CHF has had recurrent hospitalizations for this and will only require reinforcement of dietary requirements by the nurse.
Subcategory – Establishing Priorities
A nurse recognizes which of the following client rights dictates they must log out of client’s electronic medical records when not in use?
Rationale – HIPAA dictates the preservation of confidentiality of client records in all forms; verbal, written, or electronic.
Subcategory – Ethical Practice
Rationale – HIPAA dictates the preservation of confidentiality of client records in all forms; verbal, written, or electronic.
Subcategory – Ethical Practice
A nurse in the Emergency Department has been informed a client who has experienced a gunshot wound to the head and neck will be arriving. There is no family accompanying the client. When considering client consent for treatments, which of the following does the nurse plan?
Rationale – Lifesaving emergency surgery may be performed without consent. Calling family members for consent and stabilizing the client until family arrives may endanger the possibility of client rescue if there is a wait for consent. Contacting the hospital’s legal counsel is a process that may take days, weeks or months to complete.
Subcategory – Informed Consent
Rationale – Lifesaving emergency surgery may be performed without consent. Calling family members for consent and stabilizing the client until family arrives may endanger the possibility of client rescue if there is a wait for consent. Contacting the hospital’s legal counsel is a process that may take days, weeks or months to complete.
Subcategory – Informed Consent
Which statement by the student nurse indicates to the nursing instructor an understanding of the concept of quality assurance (QA)?
Rationale – It is an ongoing, systematic process to evaluate client care and promote excellence in client care. No other options fit the definition of QA.
Subcategory – Quality Improvement
Rationale – It is an ongoing, systematic process to evaluate client care and promote excellence in client care. No other options fit the definition of QA.
Subcategory – Quality Improvement
Which of the following clients would the nurse suggest a psychiatric consult for to the client’s healthcare provider?
Rationale – Frequent crying beyond the immediate postpartum period combined with the client’s disappointment are strong clues to postpartum depression. “Baby blues” are normal and often precipitated by the fatigue of adjusting to the newborn needs. An expected reminiscent behavior reflecting on the rapid changes in their infant in 1 year.
Subcategory – Referrals
Rationale – Frequent crying beyond the immediate postpartum period combined with the client’s disappointment are strong clues to postpartum depression. “Baby blues” are normal and often precipitated by the fatigue of adjusting to the newborn needs. An expected reminiscent behavior reflecting on the rapid changes in their infant in 1 year.
Subcategory – Referrals
As the nurse is admitting a client with a diagnosis of end stage COPD the client comments, “I hear they can keep you breathing forever with a ventilator.” What should be the nurse’s next question?
Rationale – The client is opening the door to a conversation about his death. Exploring the client’s wishes at the end of life is the most appropriate question. Asking the client if they have questions about artificial ventilation and asking if they would like to speak to their healthcare provider negate the client concern implied in their statement. Asking the client if they want details on their deteriorating condition does not address the topic the client touches on.
Subcategory –Case Management
Rationale – The client is opening the door to a conversation about his death. Exploring the client’s wishes at the end of life is the most appropriate question. Asking the client if they have questions about artificial ventilation and asking if they would like to speak to their healthcare provider negate the client concern implied in their statement. Asking the client if they want details on their deteriorating condition does not address the topic the client touches on.
Subcategory –Case Management
The nurse has asked a nursing assistant to help a client to the bathroom. One hour later the client asks to be assisted to the bathroom stating, “I’ve been waiting for an hour for someone to help me.” The nurse assists the client to the bathroom and back to bed. The nurse observes the nursing assistant returning from a meal in the cafeteria. What is the nurse’s next action?
Rationale – Calling the nursing supervisor to report details of the client’s complaints and the nurse’s observations is the correct procedure in following the chain of command when a problem occurs. Explaining the delay to the client and a having the nursing assistant apologize, demanding details from the assistant and questioning the nursing assistant why they did not follow through on the nurse’s directions are not appropriate actions.
Subcategory – Advocacy
Rationale – Calling the nursing supervisor to report details of the client’s complaints and the nurse’s observations is the correct procedure in following the chain of command when a problem occurs. Explaining the delay to the client and a having the nursing assistant apologize, demanding details from the assistant and questioning the nursing assistant why they did not follow through on the nurse’s directions are not appropriate actions.
Subcategory – Advocacy
A client was admitted voluntarily for treatment of a personality disorder and is now demanding to be discharged. What is the nurse’s initial action?
Rationale – This client has the right to discharge since the admission was voluntary. The healthcare provider should be notified since they are able to discuss the discharge plan with the client. Asking the client why they are demanding discharge is not a therapeutic response and can be interpreted as challenging by the client. Informing the client of financial implications of their discharge is not appropriate to discuss – only if the client signs out of the facility against medical advice. Calling the client’s family is not an appropriate option.
Subcategory – Client Rights
Rationale – This client has the right to discharge since the admission was voluntary. The healthcare provider should be notified since they are able to discuss the discharge plan with the client. Asking the client why they are demanding discharge is not a therapeutic response and can be interpreted as challenging by the client. Informing the client of financial implications of their discharge is not appropriate to discuss – only if the client signs out of the facility against medical advice. Calling the client’s family is not an appropriate option.
Subcategory – Client Rights
A nurse notes a client assigned to their care has just been admitted to the facility involuntarily. Which of the following nursing interventions should the nurse plan?
Rationale – Involuntary admission is necessary when someone poses a danger to themselves or others or requires psychiatric treatment whether they agree to the hospitalization or not. There is a potential of violence directed at the nurse with involuntary admissions. Until the client is evaluated, a quiet, calm environment is essential without any undue stress of procedures or information. Providing patient bill of rights and interpreting it if necessary is not appropriate until client’s mental state is evaluated by a healthcare provider. Revisiting details may precipitate agitation, aggression or exacerbate psychiatric symptoms.
Subcategory – Client Rights
Rationale – Involuntary admission is necessary when someone poses a danger to themselves or others or requires psychiatric treatment whether they agree to the hospitalization or not. There is a potential of violence directed at the nurse with involuntary admissions. Until the client is evaluated, a quiet, calm environment is essential without any undue stress of procedures or information. Providing patient bill of rights and interpreting it if necessary is not appropriate until client’s mental state is evaluated by a healthcare provider. Revisiting details may precipitate agitation, aggression or exacerbate psychiatric symptoms.
Subcategory – Client Rights
A client, who was admitted voluntarily, becomes physically violent to the staff. The nurse physically restrains the client while an assistant applies a vest and bilateral wrist restraints. The nurse can potentially be charged with what crime? Select all that apply.
Rationale – Confining the client to one area and forcibly restraining a client who is admitted voluntarily before attempting other alternatives to restraints constitutes assault, battery, and false imprisonment. There were no written or verbal untrue statements made about the client in this situation so slander does not pertain.
Subcategory – Client Rights
Rationale – Confining the client to one area and forcibly restraining a client who is admitted voluntarily before attempting other alternatives to restraints constitutes assault, battery, and false imprisonment. There were no written or verbal untrue statements made about the client in this situation so slander does not pertain.
Subcategory – Client Rights
The following four client situations are presented to the nurse in shift report. Which client should the nurse see first?
Rationale – A client hearing voices may have command hallucinations instructing them to harm themselves or others. A recently fired, diagnosed depressed person poses no immediate danger. Adolescent with anxiety that is failing school or an adult crying asking why they are here pose no immediate danger to themselves or others.
Subcategory – Concepts of Management
Rationale – A client hearing voices may have command hallucinations instructing them to harm themselves or others. A recently fired, diagnosed depressed person poses no immediate danger. Adolescent with anxiety that is failing school or an adult crying asking why they are here pose no immediate danger to themselves or others.
Subcategory – Concepts of Management
The nurse is caring for four clients on a medical-surgical unit. List the order that the nurse should see these clients.
Rationale – 18yr old admitted for neutropenic fever is highly susceptible to invading microbes which can be fatal to a client with a severely low WBC count so seen first. A 62yr old one day postop remains at risk for postop complications which, if not identified early, can lead to unfavorable client outcomes and increased length of stay. A 93yr old with a 3 pound weight loss daily is not unexpected as treatment for CHF causes dieresis, a favorable response to treatment. A 32yr old seen last because of their bacterial infection that can be spread by contact. All other clients would be at high risk for unfavorable outcomes if exposed to MRSA.
Subcategory – Concepts of Management
Rationale – 18yr old admitted for neutropenic fever is highly susceptible to invading microbes which can be fatal to a client with a severely low WBC count so seen first. A 62yr old one day postop remains at risk for postop complications which, if not identified early, can lead to unfavorable client outcomes and increased length of stay. A 93yr old with a 3 pound weight loss daily is not unexpected as treatment for CHF causes dieresis, a favorable response to treatment. A 32yr old seen last because of their bacterial infection that can be spread by contact. All other clients would be at high risk for unfavorable outcomes if exposed to MRSA.
Subcategory – Concepts of Management
A nurse manager hears a nurse arguing on the phone and inquires what the argument was about when the phone call has ended. The nurse replies, “The ED has stopped sending up their admission paperwork with the clients transferred to nursing units. They say they are not required to do this since the information is in the electronic medical record. It would be so much easier to have this in hard copy as I admit the client rather than going back and forth in the two areas of the electronic medical record!” Which of the following actions is best for the nurse manager to take to resolve this conflict?
Rationale – Brainstorming with the ED manager is a low stress, positive approach to the problem that can mutually benefit all involved. Asking the unit nurse to print out admission information and calling the ED manager to request hard copies unfairly put all responsibility on one group of nurses for supplying hard copy records. The issue should not wait to be addressed at the next meeting when a simple solution may be reached between the two nurse managers.
Subcategory – Concepts of Management
Rationale – Brainstorming with the ED manager is a low stress, positive approach to the problem that can mutually benefit all involved. Asking the unit nurse to print out admission information and calling the ED manager to request hard copies unfairly put all responsibility on one group of nurses for supplying hard copy records. The issue should not wait to be addressed at the next meeting when a simple solution may be reached between the two nurse managers.
Subcategory – Concepts of Management
A client care team consists of an RN, an LPN and a nursing assistant. Which of the following clients should be assigned to the LPN?
Rationale – A client needing sterile dressing is a task able to be performed by an LPN. A client with chronic fatigue syndrome needs ADL assist only, appropriate for nursing assistant assignment. A client with COPD and a client admitted with vomiting and fever have conditions with unknown etiologies that may precipitate rapid changes in conditions requiring the RN’s expertise.
Subcategory – Concepts of Management
Rationale – A client needing sterile dressing is a task able to be performed by an LPN. A client with chronic fatigue syndrome needs ADL assist only, appropriate for nursing assistant assignment. A client with COPD and a client admitted with vomiting and fever have conditions with unknown etiologies that may precipitate rapid changes in conditions requiring the RN’s expertise.
Subcategory – Concepts of Management
A student nurse recognizes they have administered a dose of a medication higher than the dose the healthcare provider ordered. The student immediately informs their instructor of the dosage error. What professional characteristic is the student demonstrating?
Rationale – The student is demonstrating they are answerable to themselves and others for their actions. Truthful is a basic principle. Competent is an expected level of performance that results from an integration of knowledge, skills, abilities, and judgment. Trustworthy is the characteristic of being reliable and worthy of trust.
Subcategory – Ethical Practice
Rationale – The student is demonstrating they are answerable to themselves and others for their actions. Truthful is a basic principle. Competent is an expected level of performance that results from an integration of knowledge, skills, abilities, and judgment. Trustworthy is the characteristic of being reliable and worthy of trust.
Subcategory – Ethical Practice
A nurse is admitting a client to their unit during the night shift. The client has an implanted device new to the implantable medical device market. The nurse has no information on this device. What is the next best action the nurse can take to safely care for their client with this device?
Rationale – Nurse’s must have strong computer literacy skills to research medications, devices, diseases and treatments they may not be familiar with to ensure client safety. Relying on the client for education or peers is not the best choice as the source of information on this new device. Waiting until morning is not safe since the device could malfunction or alarm prior to information about the device is obtained.
Subcategory – Information Technology
Rationale – Nurse’s must have strong computer literacy skills to research medications, devices, diseases and treatments they may not be familiar with to ensure client safety. Relying on the client for education or peers is not the best choice as the source of information on this new device. Waiting until morning is not safe since the device could malfunction or alarm prior to information about the device is obtained.
Subcategory – Information Technology
A client is given a dose of a medication lower than the dose ordered by the healthcare provider. The healthcare provider was notified and the client suffered no harm. Can the nurse who administered the dose be sued for malpractice?
Rationale – There must be client harm to meet the elements of malpractice. The nurse was correct in notifying the physician but this does not protect the nurse from a lawsuit. Elements of malpractice were not met. A breach of duty was evident but without client harm, malpractice cannot be asserted.
Subcategory – Legal Rights and Responsibilities
Rationale – There must be client harm to meet the elements of malpractice. The nurse was correct in notifying the physician but this does not protect the nurse from a lawsuit. Elements of malpractice were not met. A breach of duty was evident but without client harm, malpractice cannot be asserted.
Subcategory – Legal Rights and Responsibilities
The nurse is admitting a client accompanied by family. The client speaks Russian and very little, broken English. How will the nurse complete the admission interview?
Rationale –The only option legally sound in this situation. Family should never be asked to act as an interpreter related to family “screening” questions and responses as they wish. Using an English-Russian dictionary is not feasible due to time constraints on the nurse caring for other clients. Using a staff member to interpret is not safe as the nurse cannot determine the staff’s level of grasp of the foreign language.
Subcategory – Legal Rights and Responsibilities
Rationale –The only option legally sound in this situation. Family should never be asked to act as an interpreter related to family “screening” questions and responses as they wish. Using an English-Russian dictionary is not feasible due to time constraints on the nurse caring for other clients. Using a staff member to interpret is not safe as the nurse cannot determine the staff’s level of grasp of the foreign language.
Subcategory – Legal Rights and Responsibilities
A long term care facility management team has developed a list of processes already in place at the facility to analyze. The nursing staff recognizes which of the following as the purpose of this list?
Rationale – Quality improvement looks at processes and how they can be changed to improve outcomes. No other option is correct.
Subcategory – Quality Improvement
Rationale – Quality improvement looks at processes and how they can be changed to improve outcomes. No other option is correct.
Subcategory – Quality Improvement
A new nurse manager has been appointed to a nursing unit and is working toward being accepted by the nurses who have worked on the unit for years. Which of the following demonstrates the best strategy for working toward acceptance?
Rationale – Making clear assignments considering the expertise of the staff defines leadership qualities. An autocratic leader makes all the decisions without input from the staff. Laissez-faire provides little or no direction – a hands off leadership style. Sharing the vision of the future nursing unit is a characteristic of a leader.
Subcategory – Concepts of Management
Rationale – Making clear assignments considering the expertise of the staff defines leadership qualities. An autocratic leader makes all the decisions without input from the staff. Laissez-faire provides little or no direction – a hands off leadership style. Sharing the vision of the future nursing unit is a characteristic of a leader.
Subcategory – Concepts of Management
The nurse interviewing a client after a violent attack involving physical abuse by their spouse has discovered the trigger behavior precipitating the violent episode. There are no behavior descriptor choices in the electronic medical record (EMR) admission assessment for that match the trigger behavior. What is the nurse’s best option for noting this information?
Rationale – Physical assessment documentation sections include an option for entering other data not found in the assessment checklist. Additional assessment findings other than that pre-programmed into the form can be documented there. It is best to keep all assessment data gathered at one time on the same form, in the same entry in the EMR. All body system assessment data should be grouped together for ease of analysis by all members of the healthcare team. If there is any option for including the information within the EMR, it should be included. Facility policy will dictate what information is maintained electronically and in hard copy form. If this behavior is not documented, it is considered not to have assessed. Verbally reporting the behavior in addition to documenting it in the EMR is acceptable.
Subcategory – Information Technology
Rationale – Physical assessment documentation sections include an option for entering other data not found in the assessment checklist. Additional assessment findings other than that pre-programmed into the form can be documented there. It is best to keep all assessment data gathered at one time on the same form, in the same entry in the EMR. All body system assessment data should be grouped together for ease of analysis by all members of the healthcare team. If there is any option for including the information within the EMR, it should be included. Facility policy will dictate what information is maintained electronically and in hard copy form. If this behavior is not documented, it is considered not to have assessed. Verbally reporting the behavior in addition to documenting it in the EMR is acceptable.
Subcategory – Information Technology
A client that is hemodynamically stable has had caught the cause of respiratory failure reversed and is being prepared for meaning from mechanical ventilation. What members of the healthcare team should collaborate during this intervention? Select all that apply.
Rationale – The healthcare provider, respiratory therapist, and nurse should collaborate when preparing to remove a client for mechanical ventilation. The nurse manager and unlicensed assistive personnel do not need to be involved in the weaning process.
Subcategory – Collaboration with Interdisciplinary Team
Rationale – The healthcare provider, respiratory therapist, and nurse should collaborate when preparing to remove a client for mechanical ventilation. The nurse manager and unlicensed assistive personnel do not need to be involved in the weaning process.
Subcategory – Collaboration with Interdisciplinary Team
A client admitted for constipation reports a sudden onset of nausea and pain. What action by the nurse is priority?
Rationale – The nurse should first assess the client’s abdomen. Any change in a client should be assessed, prior to calling the healthcare provider. Once the assessment is completed (first phase of the nursing process), then a call can be placed. The provider would need to order the stool testing and anti-emetic medication.
Subcategory – Establishing Priorities
Rationale – The nurse should first assess the client’s abdomen. Any change in a client should be assessed, prior to calling the healthcare provider. Once the assessment is completed (first phase of the nursing process), then a call can be placed. The provider would need to order the stool testing and anti-emetic medication.
Subcategory – Establishing Priorities
The nurse is assigned the following for clients. Which client should the nurse he first?
Rationale – Heart rate of 112 is concerning a client diagnosed with aortic stenosis should be addressed prior to the client going to surgery. The client with mitral regurgitation should be seen as an elevation in temperature may indicate a potential infection and should be addressed prior to discharge. The client with hypertension has a medication schedule to be administered and should be seen but is not rarity. The client with heart failure would be expected to have shortness of breath while supine.
Subcategory – Establishing Priorities
Rationale – Heart rate of 112 is concerning a client diagnosed with aortic stenosis should be addressed prior to the client going to surgery. The client with mitral regurgitation should be seen as an elevation in temperature may indicate a potential infection and should be addressed prior to discharge. The client with hypertension has a medication schedule to be administered and should be seen but is not rarity. The client with heart failure would be expected to have shortness of breath while supine.
Subcategory – Establishing Priorities
A nurse is assigned the following for clients which client should the nurse see it first?
Rationale – A client with a history of cocaine use at any age is at increased risk for myocardial infarction and should be seen immediately.
Subcategory – Establishing Priorities
Rationale – A client with a history of cocaine use at any age is at increased risk for myocardial infarction and should be seen immediately.
Subcategory – Establishing Priorities
A patient is admitted with Cystic Fibrosis. The nurse will anticipate that the patient medication regime will include which of the following? Select all that apply.
Rationale – Clients with Cystic Fibrosis should take pancrease, vitamin A and vitamin D supplements.
Subcategory – Expected Actions/Outcomes
Rationale – Clients with Cystic Fibrosis should take pancrease, vitamin A and vitamin D supplements.
Subcategory – Expected Actions/Outcomes
An emaciated sixty-five year old male is admitted from the Emergency Room with a positive Mantoux test and positive chest x-ray noting infiltration cavitation. What teaching should be included for the client?
Rationale – INH may affect memory and concentration. Family and friends will need to be tested. The client will be placed on airborne, not contact precautions. The client will need to take the INH for a much longer period than one month.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – INH may affect memory and concentration. Family and friends will need to be tested. The client will be placed on airborne, not contact precautions. The client will need to take the INH for a much longer period than one month.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
A nurse is instructing a patient to use a metered dose inhaler for Asthma. What are the steps that should be included in the teaching? Select all that apply.
Rationale – The client should be instructed to connect the spacer to the inhaler. They will need to position the inhaler about one inch from the mouth and hold their breath for about 10 seconds after inhaling the medication.
Subcategory – Medication Administration
Rationale – The client should be instructed to connect the spacer to the inhaler. They will need to position the inhaler about one inch from the mouth and hold their breath for about 10 seconds after inhaling the medication.
Subcategory – Medication Administration
The nurse is to administer TPN (Total Parenteral Nutrition) to a patient with Crohn’s disease. The patient states an allergy to eggs. The nurse is verifying the medication and the physician order for this patient and is aware that the TPN may contain all of the following except?
Rationale – Lipids are contraindicated in clients with allergies to eggs. Insulin, electrolytes and multivitamins are not contraindicated.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Lipids are contraindicated in clients with allergies to eggs. Insulin, electrolytes and multivitamins are not contraindicated.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
The nurse administering TPN (Total Parenteral Nutrition) to a patient via a PICC (Peripherally Inserted Catheter) identifies what potential complications?
Rationale -Hyperglycemia is a complication that needs to be assessed for in clients receiving TPN. Pneumonia, weight gain and bleeding are not complications of TPN administration.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale -Hyperglycemia is a complication that needs to be assessed for in clients receiving TPN. Pneumonia, weight gain and bleeding are not complications of TPN administration.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
The nurse is assessing a client’s implanted port prior to administering chemotherapy. What action by the nurse is priority?
Rationale – It is important for the nurse to determine proper access to the port prior to Flushing or administering medications. It is important to verify medications that does not require a second nurse.
Subcategory – Pharmacological and Parenteral Therapies
Rationale – It is important for the nurse to determine proper access to the port prior to Flushing or administering medications. It is important to verify medications that does not require a second nurse.
Subcategory – Pharmacological and Parenteral Therapies
A postoperative client is having difficulty pressing the button for their morphine via patient controlled analgesia (PCA). What action by the nurse is most appropriate?
Rationale – If the client is unable to press the PCA button the family should not be instructed to press it for them. Having the client keep the button in their hand continuously is not appropriate. Requesting that the client be switched to a morphine drip is not necessary.
Subcategory – Pharmacological Pain Management
Rationale – If the client is unable to press the PCA button the family should not be instructed to press it for them. Having the client keep the button in their hand continuously is not appropriate. Requesting that the client be switched to a morphine drip is not necessary.
Subcategory – Pharmacological Pain Management
The client that has just undergone gastric bypass surgery and has the following orders for pain. Which order requires further teaching?
Rationale – A client who is undergoing gastric bypass surgery should not be prescribed ibuprofen. NSAIDs cause stomach irritation in clients that have had bypass surgery. Morphine is acceptable for severe pain. Acetaminophen ivy can be given for moderate postoperative pain hydrocodone can be given for moderate pain the nurse would have to assess acetaminophen intake to ensure that no more than 4 g is given in 24 hours.
Subcategory – Pharmacological Pain Management
Rationale – A client who is undergoing gastric bypass surgery should not be prescribed ibuprofen. NSAIDs cause stomach irritation in clients that have had bypass surgery. Morphine is acceptable for severe pain. Acetaminophen ivy can be given for moderate postoperative pain hydrocodone can be given for moderate pain the nurse would have to assess acetaminophen intake to ensure that no more than 4 g is given in 24 hours.
Subcategory – Pharmacological Pain Management
A client diagnosed with acute appendicitis has just received hydromorphone 1 mg IV prior to surgery. The client asked the nurse how long before this medication begins to work. What answer by the nurse is most appropriate?
Rationale – Hydromorphone IV takes about five minutes for onset and peaks in about 10 to 20 minutes. The nurse should give the client a timeframe for when they should expect to have relief. Pain does not go away immediately. It does not take 30 minutes before the medication works.
Subcategory – Pharmacological Pain Management
Rationale – Hydromorphone IV takes about five minutes for onset and peaks in about 10 to 20 minutes. The nurse should give the client a timeframe for when they should expect to have relief. Pain does not go away immediately. It does not take 30 minutes before the medication works.
Subcategory – Pharmacological Pain Management
A nurse is caring for a client diagnosed with hyponatremia. What order should the nurse question?
Rationale – A client with hyponatremia should not be given hypotonic solution. A client given 0.45% sodium chloride will lose sodium. Fluid restrictions are used to prevent further sodium excretion. High sodium diet will replace sodium lost. Conivaptan hydrochloride is used in clients with hyponatremia.
Subcategory – Expected Actions/Outcomes
Rationale – A client with hyponatremia should not be given hypotonic solution. A client given 0.45% sodium chloride will lose sodium. Fluid restrictions are used to prevent further sodium excretion. High sodium diet will replace sodium lost. Conivaptan hydrochloride is used in clients with hyponatremia.
Subcategory – Expected Actions/Outcomes
A client diagnosed with hypokalemia is receiving 20 mEq of potassium IV in 50 ML’s over two hours. What assessment finding indicates the need to stop the infusion?
Rationale – Urine output of 20 ML’s in two hours may indicate a renal issue. If the kidneys are not functioning properly the potassium levels may rise too quickly. Burning in the arm does not require the infusion be stopped, the nurse can decrease the rate. A sodium concentration of 145 is normal. Presence of a U wave on an ECG is consistent with a diagnosis of hypokalemia, this should improve as a potassium is infused.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Urine output of 20 ML’s in two hours may indicate a renal issue. If the kidneys are not functioning properly the potassium levels may rise too quickly. Burning in the arm does not require the infusion be stopped, the nurse can decrease the rate. A sodium concentration of 145 is normal. Presence of a U wave on an ECG is consistent with a diagnosis of hypokalemia, this should improve as a potassium is infused.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
The client receiving digitalis therapy has the following labs, magnesium 1.1 mg/dL are. Potassium 3.4 mEq/L. Sodium 146 mEq/L. Calcium 11.0 mg/dL. What lab value should be reported to the health care provider immediately?
Rationale – Client’s receiving digitalis therapy are at increased risk for digitalis toxicity when they have a low magnesium level. The potassium is slightly low in sodium slightly high but the priority would be the magnesium level.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Client’s receiving digitalis therapy are at increased risk for digitalis toxicity when they have a low magnesium level. The potassium is slightly low in sodium slightly high but the priority would be the magnesium level.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
A client admitted to the intensive care unit with a diagnosis of shock the clients been started on a Dobutamine drip. What statement by the nurse indicates a need for further teaching?
Rationale – Any vasoactive medication should be tapered to avoid severe hemodynamic instability. Dobutamine should be titrated down when the client reaches the desirable mean arterial pressure. It is slowly titrated to keep the mean arterial pressure within the desired range. Dobutamine can cause tachycardia it is a positive inotrope. A client receiving Dobutamine should have continuous cardiac monitoring.
Subcategory – Medication Administration
Rationale – Any vasoactive medication should be tapered to avoid severe hemodynamic instability. Dobutamine should be titrated down when the client reaches the desirable mean arterial pressure. It is slowly titrated to keep the mean arterial pressure within the desired range. Dobutamine can cause tachycardia it is a positive inotrope. A client receiving Dobutamine should have continuous cardiac monitoring.
Subcategory – Medication Administration
The client has Amoxicillin 0.5 grams per tube ordered. The medication is available 200 mg/5 mL’s. How many mL’s would the nurse administer? ________ mL’s.
Rationale – 500×5= 2500/200= 12.5mL’s
Subcategory – Medication Calculations
Rationale – 500×5= 2500/200= 12.5mL’s
Subcategory – Medication Calculations
The nurse has diltiazem 25 mg IV stat ordered. The medication available is 75 mg/10mL. How many mL’s should the nurse prepare? ________ mL’s
Rationale – 25×10= 250/75= 3.3 mL’s
Subcategory – Medication Calculations
Rationale – 25×10= 250/75= 3.3 mL’s
Subcategory – Medication Calculations
The client is scheduled to receive pantoprazole 40 mg IV push. The medication is reconstituted in 10 mL of normal saline and should be given over 2 minutes. How many mL’s should the nurse push a minute? _________ mL’s a minute
Rationale – 10/2= 5 mL per minute
Subcategory – Medication Calculations
Rationale – 10/2= 5 mL per minute
Subcategory – Medication Calculations
A client admitted with chronic obstructive pulmonary disease has developed acute angle closure glaucoma. What medication should be held in the prescriber notified?
Rationale – Betaxolol is a beta blocker and is contraindicated in clients with COPD. All other medications would be administered for acute angle closure glaucoma with no contraindications.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Betaxolol is a beta blocker and is contraindicated in clients with COPD. All other medications would be administered for acute angle closure glaucoma with no contraindications.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
While caring for a client diagnosed with bipolar disorder the nurse notices the client smacking their lips repetitively. What medications should be held in the healthcare provider notified? Select all that apply.
Rationale – Chlorpromazine and Haloperidol are antipsychotic drugs that have been shown to cause tardive dyskinesia, lip smacking is an example of this. Lorazepam, Ondansetron and Tetrabenazine have not been shown to cause tardive dyskinesia.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Chlorpromazine and Haloperidol are antipsychotic drugs that have been shown to cause tardive dyskinesia, lip smacking is an example of this. Lorazepam, Ondansetron and Tetrabenazine have not been shown to cause tardive dyskinesia.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
The nurse receives an order for depakene 0.75g. The medication is available in 250 per 5 mL’s. How many mL’s should the nurse prepare? _________ mL’s
Rationale – 750 x 5 mL’s = 3750/250= 15 mL’s
Subcategory – Medication Calculations
Rationale – 750 x 5 mL’s = 3750/250= 15 mL’s
Subcategory – Medication Calculations
A client with acute rhinosinusitis has been prescribed budesonide. What side effects should the nurse observed the client for? Select all that apply.
Rationale – This medication is a nasal corticosteroid and can lead to epistaxis, cough and bronchospasm. It does not cause dry throat or lightheadedness.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – This medication is a nasal corticosteroid and can lead to epistaxis, cough and bronchospasm. It does not cause dry throat or lightheadedness.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
A client diagnosed with tuberculosis would likely receive what medications in the continuation phase of treatment that begins at eight weeks after initial treatment? Select all that apply.
Rationale –INH and Rifampin are used in the continuation fees of tuberculosis in addition to being used during the initial intensive treatment. All other medications are only used in the intensive initial treatment for eight weeks.
Subcategory – Expected Actions/Outcomes
Rationale –INH and Rifampin are used in the continuation fees of tuberculosis in addition to being used during the initial intensive treatment. All other medications are only used in the intensive initial treatment for eight weeks.
Subcategory – Expected Actions/Outcomes
The client diagnosed with Addison’s disease is prescribed hydrocortisone to treat the disorder. What interventions by the client indicates teaching was effective? Select all that apply.
Rationale – Client’s taking hydrocortisone for Addison’s disease should take oral dose is with meals, avoid immunizations during therapy and for three months after and implement a weight reduction diet. They should not discontinue the medications one feeling better, the medication needs to be tapered. If they miss a dose they should take it when they remember if it is on the same day.
Subcategory – Medication Administration
Rationale – Client’s taking hydrocortisone for Addison’s disease should take oral dose is with meals, avoid immunizations during therapy and for three months after and implement a weight reduction diet. They should not discontinue the medications one feeling better, the medication needs to be tapered. If they miss a dose they should take it when they remember if it is on the same day.
Subcategory – Medication Administration
The client with diarrhea has been prescribed bismuth subsalicylate. After receiving teaching what statement by the client indicates a need for further teaching?
Rationale – Aspirin should be avoided when clients are taking bismuth subsalicylate because there is a substantial risk for salicylate toxicity taking both. They should take the medication when they have diarrhea. They should shake the medication before taking it. They should not eat solid foods for 24 hours after diarrhea subsides.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Aspirin should be avoided when clients are taking bismuth subsalicylate because there is a substantial risk for salicylate toxicity taking both. They should take the medication when they have diarrhea. They should shake the medication before taking it. They should not eat solid foods for 24 hours after diarrhea subsides.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
The nurse is caring for a client diagnosed with Crohn’s disease that has been prescribed diphenoxylate hydrochloride. What teaching by the nurse is appropriate?
Rationale – Milk and caffeine should be avoided as it will aggravate diarrhea. A client taking diphenoxylate hydrochloride should increase not decrease fluid intake. There is no contraindication with aspirin and this medication. They should not eat food such as bananas rice or applesauce when diarrhea is occurring they should wait 24 hours to eat solid food.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Milk and caffeine should be avoided as it will aggravate diarrhea. A client taking diphenoxylate hydrochloride should increase not decrease fluid intake. There is no contraindication with aspirin and this medication. They should not eat food such as bananas rice or applesauce when diarrhea is occurring they should wait 24 hours to eat solid food.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
The client diagnosed with irritable bowel syndrome has received teaching on a new medication, dicyclomine hydrochloride. What side effects if chosen by the client indicates the teaching was effective? Select all that apply.
Rationale – Side effects of dicyclomine hydrochloride include headache, dry mouth and drowsiness. Urinary incontinence and diarrhea are not side effects of this medication.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Side effects of dicyclomine hydrochloride include headache, dry mouth and drowsiness. Urinary incontinence and diarrhea are not side effects of this medication.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
A client that has been taking haloperidol for schizophrenia has a new diagnosis of Graves disease. What lab should be monitored for a potential complication with using these two drugs?
Rationale – The white blood cell count should be monitored. Agranulocytosis is a potential complication of antipsychotic medications and anti-thyroid agents. Potassium, hemoglobin and bilirubin are not altered by the combination of these two drugs.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – The white blood cell count should be monitored. Agranulocytosis is a potential complication of antipsychotic medications and anti-thyroid agents. Potassium, hemoglobin and bilirubin are not altered by the combination of these two drugs.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
A client that has decided to stop drinking alcohol has been given an order for disulfiram. What statement by the client indicates a need for further teaching?
Rationale – Disulfiram should not be taken within 12 hours of alcohol consumption. The client may have drowsiness and it should improve over time. The client could have acetaldehyde syndrome which occurs when the client drinks alcohol while taking this medication one of the effects could be a heart attack, myocardial infarction. Because the medication has a long half-life it will stay in their system for up to two weeks, the client should not drink for two weeks after stopping the medication.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Disulfiram should not be taken within 12 hours of alcohol consumption. The client may have drowsiness and it should improve over time. The client could have acetaldehyde syndrome which occurs when the client drinks alcohol while taking this medication one of the effects could be a heart attack, myocardial infarction. Because the medication has a long half-life it will stay in their system for up to two weeks, the client should not drink for two weeks after stopping the medication.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Neuroleptic malignant syndrome or, a complication of antipsychotic medications is characterized by what signs and symptoms? Select all that apply.
Rationale – Signs and symptoms of neuroleptic malignant syndrome include catatonia dyspnea and incontinence. Hyperthermia and not hypothermia is often seen. Patients are often profusely sweating not dry.
Subcategory – Potential Alterations in Body Systems
Rationale – Signs and symptoms of neuroleptic malignant syndrome include catatonia dyspnea and incontinence. Hyperthermia and not hypothermia is often seen. Patients are often profusely sweating not dry.
Subcategory – Potential Alterations in Body Systems
A client is scheduled to receive cough syrup and several oral tablets at the same time. What action by the nurse is most appropriate?
Rationale – Administering the tablets should be done first. Cough syrup should always be given after oral medications.
Subcategory – Medication Administration
Rationale – Administering the tablets should be done first. Cough syrup should always be given after oral medications.
Subcategory – Medication Administration
A client diagnosed with a urinary tract infection is scheduled for the following medications at 0900 with breakfast, Ciprofloxacin, Digoxin and Magnesium hydroxide. What action by the nurse is most appropriate?
Rationale – Ciprofloxacin should not be given with multivitamins or magnesium. They should be avoided with milk or milk products which may also coincide with breakfast. The other medications can be given at breakfast however the ciprofloxacin should be held until two hours after milk products, vitamins or magnesium hydroxide.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Ciprofloxacin should not be given with multivitamins or magnesium. They should be avoided with milk or milk products which may also coincide with breakfast. The other medications can be given at breakfast however the ciprofloxacin should be held until two hours after milk products, vitamins or magnesium hydroxide.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
What instructions should be included for a client taking Benzonatate?
Rationale – Benzonatate (Tessalon Perles) should not be chewed. The client should swallow the capsule whole. The medication does not treat infection. The client will not need to check their post. The client will likely still have coughing but reduced coughing with this medication.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Benzonatate (Tessalon Perles) should not be chewed. The client should swallow the capsule whole. The medication does not treat infection. The client will not need to check their post. The client will likely still have coughing but reduced coughing with this medication.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
A nurse receives report from EMS that they are transporting a client in status epilepticus. What medication should the nurse have available?
Rationale – Diazepam is used in the treatment of status epilepticus. The other medications are not used to treat status epilepticus in the emergent phase.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Diazepam is used in the treatment of status epilepticus. The other medications are not used to treat status epilepticus in the emergent phase.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
The client diagnosed with Alzheimer’s disease is receiving donepezil. The family as a nurse why the client is receiving the medication. What statement by the nurse is accurate?
Rationale – The medication is a cholinesterase inhibitor or that will prevent the breakdown of acetylcholine and allow better functioning of the nervous system. It does not stimulate the dopamine receptors. It doesn’t block the metabolism of dopamine and it will not block the action of acetylcholine.
Subcategory – Expected Actions/Outcomes
Rationale – The medication is a cholinesterase inhibitor or that will prevent the breakdown of acetylcholine and allow better functioning of the nervous system. It does not stimulate the dopamine receptors. It doesn’t block the metabolism of dopamine and it will not block the action of acetylcholine.
Subcategory – Expected Actions/Outcomes
What intervention is recommended for a client that has been undergoing radiation therapy that is experiencing mucositis?
Rationale – Oral lidocaine may help reduce pain and clients with mucositis. Cold fluids are not recommended. Citrus juice and commercial mouthwash would both irritate the mouth.
Subcategory – Expected Actions/Outcomes
Rationale – Oral lidocaine may help reduce pain and clients with mucositis. Cold fluids are not recommended. Citrus juice and commercial mouthwash would both irritate the mouth.
Subcategory – Expected Actions/Outcomes
A client admitted to the hospital with full thickness burns on both legs has scabbed over necrotic areas. When reviewing medications what topical treatment does the nurse anticipate administering?
Rationale – Silver sulfadiazine is a commonly used topical treatment for burns. The other medications not commonly used in the early stages of burns.
Subcategory – Expected Actions/Outcomes
Rationale – Silver sulfadiazine is a commonly used topical treatment for burns. The other medications not commonly used in the early stages of burns.
Subcategory – Expected Actions/Outcomes
A client diagnosed with shingles has been prescribed acyclovir. What statement by the client reflects a need for further teaching?
Rationale – The rash will not be gone in 3 to 4 days. It takes longer for the rash to resolve. The medication will control the outbreak. It should it not be stopped abruptly as the rash may get worse. People are still able to contract the virus if the client is on medication.
Subcategory – Expected Actions/Outcomes
Rationale – The rash will not be gone in 3 to 4 days. It takes longer for the rash to resolve. The medication will control the outbreak. It should it not be stopped abruptly as the rash may get worse. People are still able to contract the virus if the client is on medication.
Subcategory – Expected Actions/Outcomes
A client scheduled for a radical mastectomy decide to have family members donate blood in the event it is needed. The client is type a negative blood. What blood types can be used? Select all that apply.
Rationale – Type A or O negative are acceptable for transfusion and a client that is a negative.
Subcategory – Blood and Blood Products
Rationale – Type A or O negative are acceptable for transfusion and a client that is a negative.
Subcategory – Blood and Blood Products
A client asks the nurse the purpose of a new inhaler, albuterol, for treatment of their asthma. What statement by the nurse is appropriate?
Rationale – Albuterol is a bronchodilator to help in the treatment of asthma. It does not decrease inflammation and it does not decrease production of mucus and airways. It does not cause bronchospasms.
Subcategory – Expected Actions/Outcomes
Rationale – Albuterol is a bronchodilator to help in the treatment of asthma. It does not decrease inflammation and it does not decrease production of mucus and airways. It does not cause bronchospasms.
Subcategory – Expected Actions/Outcomes
A client diagnosed with asthma has been prescribed salmeterol. What statement by the client indicates that discharge teaching regarding this medication was effective?
Rationale – This medication is prescribed every 12 hours for clients with asthma. It is not used as a rescue inhaler or in use for an asthma attack. The medication should not be given every four hours.
Subcategory – Medication Administration
Rationale – This medication is prescribed every 12 hours for clients with asthma. It is not used as a rescue inhaler or in use for an asthma attack. The medication should not be given every four hours.
Subcategory – Medication Administration
A client prescribed oral prednisone has been given information on side effects that would need to be reported to the healthcare provider. What side effects selected by the client indicates the teaching was effective? Select all that apply.
Rationale – Side effects that need to be reported to the health care provider immediately include fluid retention, nervousness and dyspnea. Slowed heart rate and drowsiness are not side effects of prednisone.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Side effects that need to be reported to the health care provider immediately include fluid retention, nervousness and dyspnea. Slowed heart rate and drowsiness are not side effects of prednisone.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
The nurse is caring for a client with terminal cancer that has been receiving morphine sulfate 4 mg IV every four hours for the past two weeks for analgesia. The client is now stating that the pain is still present even after the medication has been administered. What does this finding indicate to the nurse?
Rationale – After taking the pain medication for a period of time a client will often develop a tolerance, needing a higher dose of the medication for the same pain relief. This does not mean that the client is addicted, has a physical dependence or would need to be switched to a different medication.
Subcategory – Expected Actions/Outcomes
Rationale – After taking the pain medication for a period of time a client will often develop a tolerance, needing a higher dose of the medication for the same pain relief. This does not mean that the client is addicted, has a physical dependence or would need to be switched to a different medication.
Subcategory – Expected Actions/Outcomes
What is the priority side effect for the nurse to assess four and a client that is receiving morphine?
Rationale – Respiratory depression is the most serious side effects of morphine and should be monitored closely for in a client receiving morphine.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Respiratory depression is the most serious side effects of morphine and should be monitored closely for in a client receiving morphine.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
A client diagnosed with breast cancer is receiving cyclophosphamide 7 mg two times a week for maintenance therapy. What lab values should the nurse monitor closely?
Rationale – Cyclophosphamide can significantly alter the white blood cell count. White blood cell count should be monitored closely and any alterations should be reported to the health care provider immediately. The medication will not alter the estrogen, uric acid or magnesium levels.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – Cyclophosphamide can significantly alter the white blood cell count. White blood cell count should be monitored closely and any alterations should be reported to the health care provider immediately. The medication will not alter the estrogen, uric acid or magnesium levels.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
A client with AIDS is diagnosed with an oral candidiasis. What medication does nurse anticipate administering to this client?
Rationale –Fluconazole is an antifungal medication it can be used for oral candidiasis. Crixivan, Azithromycin and Metoclopramide will not treat oral candidiasis.
Subcategory – Expected Actions/Outcomes
Rationale –Fluconazole is an antifungal medication it can be used for oral candidiasis. Crixivan, Azithromycin and Metoclopramide will not treat oral candidiasis.
Subcategory – Expected Actions/Outcomes
After receiving an intramuscular injection of diazepam for muscle spasms, how long should a client remain in an emergency department prior to being discharged?
Rationale – When administering an intramuscular medication, the nurse should wait 2 1/2 to 3 hours prior to discharging them to ensure that the medication worked in the door minimal side effects. Discharging the client within 30 minutes to one hour will not allow the nurse to determine if the client has had relief of symptoms. Making the client wait eight hours is not necessary.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
Rationale – When administering an intramuscular medication, the nurse should wait 2 1/2 to 3 hours prior to discharging them to ensure that the medication worked in the door minimal side effects. Discharging the client within 30 minutes to one hour will not allow the nurse to determine if the client has had relief of symptoms. Making the client wait eight hours is not necessary.
Subcategory – Adverse Effects/Contraindications/Side Effects/Interactions
A client experiencing a flare of systemic lupus erythematosus has been prescribed prednisone, 60 mg PO, in three equal doses. The nurse should administer ______ 5 mg tablets three times each day.
Rationale – 60 mg / 3 equal doses = 20 mg each dose, 20 mg each dose / 5 mg tablets is 4 tablets.
Subcategory – Medication Calculation
Rationale – 60 mg / 3 equal doses = 20 mg each dose, 20 mg each dose / 5 mg tablets is 4 tablets.
Subcategory – Medication Calculation
A client diagnosed with hyponatremia would likely have what clinical manifestations? Select all that apply.
Rationale – A client diagnosed with hyponatremia would often have decreased turgor, headache and altered mental status. Hypertension is not a symptom of hyponatremia. Clients often have orthostatic hypotension. Body temperature increases are seen in hypernatremia.
Subcategory – Fluid and Electrolyte Imbalances
Rationale – A client diagnosed with hyponatremia would often have decreased turgor, headache and altered mental status. Hypertension is not a symptom of hyponatremia. Clients often have orthostatic hypotension. Body temperature increases are seen in hypernatremia.
Subcategory – Fluid and Electrolyte Imbalances
A client with a pH of 7.30, a PaCO2 of 55 and HCO3 of 28 is likely experiencing what type of acid-base disorder?
Rationale – A client with respiratory acidosis is compensating and will have an increase in the HCO3 greater than 26 mEq/L. The client is not experiencing metabolic acidosis as the bicarb would be low, not high. The client does not have alkalosis.
Subcategory – Fluid and Electrolyte
Rationale – A client with respiratory acidosis is compensating and will have an increase in the HCO3 greater than 26 mEq/L. The client is not experiencing metabolic acidosis as the bicarb would be low, not high. The client does not have alkalosis.
Subcategory – Fluid and Electrolyte
The client returns to the Emergency Department 8 hours after having been treated for the flu. The client is now severely dyspneic, O2 saturation 83% on 100% NRB, and shows evidence of circumoral cyanosis. The nurse knows to expect which of the following to occur while the patient is in the Emergency Department?
Rationale- The client is presenting with symptoms of Acute Respiratory Distress Syndrome (ARDs). ARDs occurs within 24 hours of initial pulmonary insult, in this case, the flu. Rapid Sequence Intubation will provide ventilator support for this patient. The patient may have a tracheostomy and PICC line at some point if indicated, however not in the initial phase of Emergency Treatment. The patient will not require reverse isolation unless otherwise compromised.
Subcategory- Medical Emergencies
Rationale- The client is presenting with symptoms of Acute Respiratory Distress Syndrome (ARDs). ARDs occurs within 24 hours of initial pulmonary insult, in this case, the flu. Rapid Sequence Intubation will provide ventilator support for this patient. The patient may have a tracheostomy and PICC line at some point if indicated, however not in the initial phase of Emergency Treatment. The patient will not require reverse isolation unless otherwise compromised.
Subcategory- Medical Emergencies
The client is discharged home after receiving a diagnosis of COPD. The client is now required to take an inhaled corticosteroid every day. Which statement, if made by the client, shows comprehension of the discharge teaching?
Rationale- Corticosteroid inhalers can cause fungal mouth infections such as thrush. Clients should be instructed to rinse their mouth out after each use in order to avoid this complication. Corticosteroid inhalers can be taken at any time during the day, are to be taken every day while prescribed, and are not to be stopped unless directed by a physician.
Subcategory- Illness Management
Rationale- Corticosteroid inhalers can cause fungal mouth infections such as thrush. Clients should be instructed to rinse their mouth out after each use in order to avoid this complication. Corticosteroid inhalers can be taken at any time during the day, are to be taken every day while prescribed, and are not to be stopped unless directed by a physician.
Subcategory- Illness Management
A client is brought to the Emergency Department by her daughter. The client is complaining of dysphasia, mild drooling from her left side of her mouth, and weakness in her left hand. The daughter found the client with these symptoms when she went to pick her up for an appointment. What is the most important question for the nurse to ask?
Rationale- This client is presenting with symptoms of a stroke. It is imperative to ask when the client was last seen “normal” in order to direct the care and treatment of the client. The other questions are important to ask, but not the most important in this situation.
Subcategory- Medical Emergencies
Rationale- This client is presenting with symptoms of a stroke. It is imperative to ask when the client was last seen “normal” in order to direct the care and treatment of the client. The other questions are important to ask, but not the most important in this situation.
Subcategory- Medical Emergencies
A client is admitted to the hospital with abdominal pain and is diagnosed with acute liver failure. Two days later, the client’s family approaches the nurse and reports that their mother seems confused. The nurse knows that this may be related to which of the following?
Rationale- Client’s with liver failure are at risk for hepatic encephalopathy, a rise in ammonia levels that effect the brain and causes acute confusion. While dehydration and UTI can cause confusion, it is not the most likely cause for this client. Decreased sodium levels can cause acute confusion, not elevated.
Subcategory- Pathophysiology
Rationale- Client’s with liver failure are at risk for hepatic encephalopathy, a rise in ammonia levels that effect the brain and causes acute confusion. While dehydration and UTI can cause confusion, it is not the most likely cause for this client. Decreased sodium levels can cause acute confusion, not elevated.
Subcategory- Pathophysiology
A client is admitted to the med/surg floor following abdominal surgery. On post-op day #1, the client is found to have a low grade fever (99.20F). The nurse knows that this is most likely due to which of the following?
Rationale- The most common cause of a low grade fever in the immediate post-op period is atelectasis. Infection can cause a fever, however not by post-op day #1 unless the infection was present prior to surgery. Tachycardia and pain should not directly cause a low grade fever
Subcategory- Pathophysiology
Rationale- The most common cause of a low grade fever in the immediate post-op period is atelectasis. Infection can cause a fever, however not by post-op day #1 unless the infection was present prior to surgery. Tachycardia and pain should not directly cause a low grade fever
Subcategory- Pathophysiology
A client presents to the Emergency Department with pain in his chest and shortness of breath. The client reports just returning from an overseas flight two days ago. The nurse knows to anticipate which of the following diagnostic tests?
Rationale- The client is exhibiting symptoms of a Pulmonary Embolism which correlates with his recent travel history and probability of having had a DVT. A CT Angiography of the Chest is used to diagnose PEs. The other tests are not used to confirm a diagnosis of Pulmonary Embolism.
Subcategory- Medical Emergencies
Rationale- The client is exhibiting symptoms of a Pulmonary Embolism which correlates with his recent travel history and probability of having had a DVT. A CT Angiography of the Chest is used to diagnose PEs. The other tests are not used to confirm a diagnosis of Pulmonary Embolism.
Subcategory- Medical Emergencies
A client returns to the hospital unit after receiving a Triple Lumen Catheter (TLC) in their subclavian vein. That evening, the client begins to complain of shortness of breath, her O2 saturation on room air is 86%, and the nurse auscultates diminished lung sounds in the left upper lobes. The nurse calls the physician to notify him that which of the following may have occurred?
Rationale- A potential complication of TLC placement is a pneumothorax. The client’s symptoms suggest this may have occurred.
Subcategory- Unexpected Response to Therapy
Rationale- A potential complication of TLC placement is a pneumothorax. The client’s symptoms suggest this may have occurred.
Subcategory- Unexpected Response to Therapy
A client is being treated for hypovolemia. The nurse knows that the client’s treatment has been ineffective when she obtains which of the following vital signs?
Rationale- Hypotension and tachycardia together are signs of hypovolemia. A BP of 132/76 and pulse of 55 would show improvement. The BP of 98/56 and pulse of 76 would show some improvement and the BP of 127/85 and pulse of 107 would signify improvement.
Subcategory- Illness Management
Rationale- Hypotension and tachycardia together are signs of hypovolemia. A BP of 132/76 and pulse of 55 would show improvement. The BP of 98/56 and pulse of 76 would show some improvement and the BP of 127/85 and pulse of 107 would signify improvement.
Subcategory- Illness Management
A client presents to the Emergency Department with right upper quadrant pain, fever, chills, and tachycardia, and guarding. Which of the following interventions should the nurse do first?
Rationale- The nurse should be anticipating emergency surgery for a cholecystectomy and should insert a large-bore IV to prepare for obtaining blood samples, administering pain medication and IV fluids, and eventual anesthesia. Calling phlebotomy, getting the client in a hospital gown, and rechecking the client’s temperature are not priority.
Subcategory- Medical Emergencies
Rationale- The nurse should be anticipating emergency surgery for a cholecystectomy and should insert a large-bore IV to prepare for obtaining blood samples, administering pain medication and IV fluids, and eventual anesthesia. Calling phlebotomy, getting the client in a hospital gown, and rechecking the client’s temperature are not priority.
Subcategory- Medical Emergencies
The client was admitted to the Intensive Care Unit yesterday for bilateral Pulmonary Emboli and is on a heparin drip. The client develops epistaxis that does not stop after the nurse applies pressure to the nares. What should the nurse do first?
Rationale- The client is showing signs of over-anticoagulation and the nurse must first stop the heparin drip and then call the physician. The client should also continue holding pressure if able. A blood sample for PTT will also need to happen, however not first.
Subcategory- Unexpected Response to Therapy
Rationale- The client is showing signs of over-anticoagulation and the nurse must first stop the heparin drip and then call the physician. The client should also continue holding pressure if able. A blood sample for PTT will also need to happen, however not first.
Subcategory- Unexpected Response to Therapy
A client is admitted to the Medical/Surgical unit with a chief complaint of painful bilateral lower extremity edema. The nurse observes that the client has 2+ pitting edema in both lower legs/ankles. The nurse suspects the client has new onset congestive heart failure. What medications will the nurse expect to administer?
Rationale- The nurse should anticipate administering Furosemide, a loop diuretic, to aid in the extra fluid removal in this client. While Lisinopril, Diltiazem, and Metoprolol can be given for cardiac issues, they are not given in every instance of congestive heart failure.
Subcategory- Fluid and Electrolytes
Rationale- The nurse should anticipate administering Furosemide, a loop diuretic, to aid in the extra fluid removal in this client. While Lisinopril, Diltiazem, and Metoprolol can be given for cardiac issues, they are not given in every instance of congestive heart failure.
Subcategory- Fluid and Electrolytes
A client presents to the Emergency Department with complaints of dizziness, fatigue, and acid reflux pain. Which of the following place the client at higher risk of these symptoms being cardiac-related? Select all that apply.
Rationale- Age, gender, and smoking history are all major risk factors for cardiac disease. Hepatitis and COPD history are not directly related to cardiac disease.
Subcategory- Medical Emergencies
Rationale- Age, gender, and smoking history are all major risk factors for cardiac disease. Hepatitis and COPD history are not directly related to cardiac disease.
Subcategory- Medical Emergencies
A client presents to the emergency department with complaints of nausea, vomiting, and abdominal pain. ABGs are obtained. The nurse knows to expect which diagnosis?
Rationale- Excessive vomiting depletes the body of acid, thereby causing a state of Metabolic Alkalosis. Nausea, vomiting, and abdominal pain do not reflect a respiratory issue.
Subcategory- Pathophysiology
Rationale- Excessive vomiting depletes the body of acid, thereby causing a state of Metabolic Alkalosis. Nausea, vomiting, and abdominal pain do not reflect a respiratory issue.
Subcategory- Pathophysiology
A client presents to the hospital with pain in her right great toe joint which is exacerbated by walking and is worse in the morning when first getting up. The nurse knows that this could be indicative of which of the following?
Rationale- The client is experiencing symptoms of gout. Gout is caused by an increase in uric acid levels within the body which can be depicted in laboratory testing.
Subcategory- Alterations in Body Systems
Rationale- The client is experiencing symptoms of gout. Gout is caused by an increase in uric acid levels within the body which can be depicted in laboratory testing.
Subcategory- Alterations in Body Systems
A client presents to the Emergency Department after a motor vehicle accident with an open left foot fracture. Which of the following is the priority nursing assessment?
Rationale- The priority nursing assessment with an open foot fracture is to assess the pedal pulses. Strong pedal pulses represent no interruption of blood flow to the distal foot which would be considered a medical emergency. While vital signs, neuro, and respiratory are important assessments, they are not the priority for this.
Subcategory- Medical Emergencies
Rationale- The priority nursing assessment with an open foot fracture is to assess the pedal pulses. Strong pedal pulses represent no interruption of blood flow to the distal foot which would be considered a medical emergency. While vital signs, neuro, and respiratory are important assessments, they are not the priority for this.
Subcategory- Medical Emergencies
While caring for a postoperative client the nurse notices the wound is red and swollen with purulent drainage. The client’s white blood cell count is 11,000. What action by the nurse is priority?
Rationale – The nurse should notify the healthcare provider who will give the nurse orders for cultures, repeat bloodwork and antibiotics.
Subcategory – Alterations in Body Systems
Rationale – The nurse should notify the healthcare provider who will give the nurse orders for cultures, repeat bloodwork and antibiotics.
Subcategory – Alterations in Body Systems
PaO2 90 mmHg. What acid-base imbalance does the nurse suspect?
Rationale – Respiratory acidosis is a pH below 7.35 with the PaCO2 greater than 45. The bicarb is normal which indicates it is not a metabolic disorder.
Subcategory – Alterations in Body Systems
Rationale – Respiratory acidosis is a pH below 7.35 with the PaCO2 greater than 45. The bicarb is normal which indicates it is not a metabolic disorder.
Subcategory – Alterations in Body Systems
A client has received teaching regarding triglycerides, cholesterol and heart disease. What statement by the client indicates the teaching was effective?
Rationale- Triglyceride levels should be less than 130 mg/dL, 70 mg/dL is an optimal level. The HDL should be above 60 mg/dL, the total cholesterol should be under 200 mg/dL and the LDL level should be lower than 130 mg/dL.
Subcategory- Pathophysiology
Rationale- Triglyceride levels should be less than 130 mg/dL, 70 mg/dL is an optimal level. The HDL should be above 60 mg/dL, the total cholesterol should be under 200 mg/dL and the LDL level should be lower than 130 mg/dL.
Subcategory- Pathophysiology
What statement by the nurse demonstrates and accurate explanation of the physiology of mitral valve regurgitation?
Rationale- Mitral valve regurgitation leads to backflow of blood into the left atrium. The mitral valve is on the left side of the heart between the atrium and ventricle, which would not affect the right atrium or ventricle. Excess blood is not pushed into the left ventricle, it is pushed back into the atrium.
Subcategory- Pathophysiology
Rationale- Mitral valve regurgitation leads to backflow of blood into the left atrium. The mitral valve is on the left side of the heart between the atrium and ventricle, which would not affect the right atrium or ventricle. Excess blood is not pushed into the left ventricle, it is pushed back into the atrium.
Subcategory- Pathophysiology
A client diagnosed with bradycardia has just had a pacemaker implanted. What teaching by the nurse is appropriate?
Rationale- It is important to teach clients with pacemakers to check their pulse regularly. They do not need to avoid microwaves. They will not need to be on bedrest or take anticoagulants for the rest of their lives.
Subcategory- Illness Management
Rationale- It is important to teach clients with pacemakers to check their pulse regularly. They do not need to avoid microwaves. They will not need to be on bedrest or take anticoagulants for the rest of their lives.
Subcategory- Illness Management
While caring for a client that has a closed drainage system, a family member trips on the tubing and the tube from the drainage collection chamber becomes dislodged. What action should the nurse take first?
Rationale- The priority intervention when the tubing from a chest tube is dislodged is to submerge the tube in sterile water or saline. The vital signs should be assessed after the tube is secured and submerged. The healthcare provider should be contacted after the tube is secured and reconnected. A new set up is warranted, but not until after the tube is submerged and client stabilized.
Subcategory- Medical Emergencies
Rationale- The priority intervention when the tubing from a chest tube is dislodged is to submerge the tube in sterile water or saline. The vital signs should be assessed after the tube is secured and submerged. The healthcare provider should be contacted after the tube is secured and reconnected. A new set up is warranted, but not until after the tube is submerged and client stabilized.
Subcategory- Medical Emergencies
A client diagnosed with hypertension has a new order for hydrochlorothiazide. What findings should be reported to the healthcare provider prior to administering the medication? Select all that apply.
Rationale- Allergies to sulfonamides would indicate the client should not receive this mediation. A potassium level of 3.0 mEq/L should be treated prior to the client receiving hydrochlorothiazide. The sodium level is normal. A blood pressure of 140/90 mm/Hg is the reason the client is scheduled to start the medication. A recent administration of metoprolol is not a contraindication for receiving hydrochlorothiazide.
Subcategory- Unexpected Response to Therapies
Rationale- Allergies to sulfonamides would indicate the client should not receive this mediation. A potassium level of 3.0 mEq/L should be treated prior to the client receiving hydrochlorothiazide. The sodium level is normal. A blood pressure of 140/90 mm/Hg is the reason the client is scheduled to start the medication. A recent administration of metoprolol is not a contraindication for receiving hydrochlorothiazide.
Subcategory- Unexpected Response to Therapies
A client that is experiencing pulmonary edema has retraction, pink frothy sputum and diaphoresis. Their blood pressure is 184/88 mm/Hg, pulse is 118 and respirations are 34. The nurse administers prescribed furosemide. What is the desired response to the administration of this medication?
Rationale- Diuretics, such as furosemide, may be administered to reduce preload in clients with pulmonary edema. A decrease in blood pressure should be observed. It will not reduce the respirations significantly. An increase in pulmonary artery wedge pressure would be a negative finding. The pulse should be reduced more than 3 beats per minute.
Subcategory- Illness Management
Rationale- Diuretics, such as furosemide, may be administered to reduce preload in clients with pulmonary edema. A decrease in blood pressure should be observed. It will not reduce the respirations significantly. An increase in pulmonary artery wedge pressure would be a negative finding. The pulse should be reduced more than 3 beats per minute.
Subcategory- Illness Management
A client that has just undergone nasal surgery for a deviated septum has received discharge teaching. What statement by the client indicated the teaching was effective?
Rationale- It is important that clients undergoing nasal surgery avoid coughing and blowing their nose after surgery. They should not take pain medication every hour, often it is every 4-6 hours. They should increase fluid intake, not restrict it. They do not need to have clear liquids, they will resume their pre-surgery diet.
Subcategory- Illness Management
Rationale- It is important that clients undergoing nasal surgery avoid coughing and blowing their nose after surgery. They should not take pain medication every hour, often it is every 4-6 hours. They should increase fluid intake, not restrict it. They do not need to have clear liquids, they will resume their pre-surgery diet.
Subcategory- Illness Management
What signs and symptoms does the nurse anticipate in a client diagnosed with hypothyroidism? Select all that apply.
Rationale- Dry skin, weight gain and cold intolerance are common findings in clients with hypothyroidism. Constipation, not diarrhea and bradycardia, not tachycardia are common.
Subcategory- Alterations in Body Systems
Rationale- Dry skin, weight gain and cold intolerance are common findings in clients with hypothyroidism. Constipation, not diarrhea and bradycardia, not tachycardia are common.
Subcategory- Alterations in Body Systems
A client admitted to the Emergency Department in acute respiratory failure would likely experience what acid-base abnormality?
Rationale- Respiratory acidosis is the acid base abnormality that most often occurs in acute respiratory failure. Metabolic disorders are not often caused by respiratory issues and respiratory alkalosis is not a result of respiratory failure.
Subcategory- Medical Emergencies
Rationale- Respiratory acidosis is the acid base abnormality that most often occurs in acute respiratory failure. Metabolic disorders are not often caused by respiratory issues and respiratory alkalosis is not a result of respiratory failure.
Subcategory- Medical Emergencies
A client presents to the Emergency Department with a penetrating stab wound. The knife is still in the clients flank area. What action by the nurse is priority?
Rationale- The priority nursing intervention is to stabilize the knife. Once the knife is stabilized vital signs should be assessed and an IV catheter inserted. The client’s position would depend on where in the flank the knife is and what their vital signs reveal.
Subcategory- Medical Emergencies
Rationale- The priority nursing intervention is to stabilize the knife. Once the knife is stabilized vital signs should be assessed and an IV catheter inserted. The client’s position would depend on where in the flank the knife is and what their vital signs reveal.
Subcategory- Medical Emergencies
A client diagnosed with Addison’s disease reports fatigue. What should the nurse assess for?
Rationale- Hypoglycemia is often found in clients with Addison’s disease and would cause fatigue. Tachycardia and hyperkalemia would not cause fatigue. Hypercalcemia is often found in clients with Addison’s.
Subcategory- Illness Management
Rationale- Hypoglycemia is often found in clients with Addison’s disease and would cause fatigue. Tachycardia and hyperkalemia would not cause fatigue. Hypercalcemia is often found in clients with Addison’s.
Subcategory- Illness Management
The student nurse learned about the signs and symptoms of diabetic ketoacidosis. What selections by the student indicate the teaching was effective? Select all that apply.
Rationale- Polyuria, flulike symptoms and Kussmaul’s respirations are all indications of diabetic ketoacidosis. Hypertension and peripheral edema are not associated with diabetic ketoacidosis.
Subcategory- Illness Management
Rationale- Polyuria, flulike symptoms and Kussmaul’s respirations are all indications of diabetic ketoacidosis. Hypertension and peripheral edema are not associated with diabetic ketoacidosis.
Subcategory- Illness Management
A client with Chronic Obstructive Pulmonary Disease (COPD) would likely have what assessment findings? Select all that apply.
Rationale- Polycythemia, dyspnea at rest and clubbing of the fingers are assessment findings consistent with COPD. Pigeon chest and subcutaneous emphysema are not findings consistent with COPD.
Subcategory- Alterations in Body Systems
Rationale- Polycythemia, dyspnea at rest and clubbing of the fingers are assessment findings consistent with COPD. Pigeon chest and subcutaneous emphysema are not findings consistent with COPD.
Subcategory- Alterations in Body Systems
A client admitted with a diagnosis of urosepsis has received their first dose of IV antibiotics. The client reports pruritus and has audible wheezes. What action by the nurse is priority?
Rationale- The client is exhibiting symptoms of an anaphylactic reaction. The nurse should immediately discontinue the antibiotic, then check the vital signs and call for an order of diphenhydramine. There is no indication to initiate a code blue.
Subcategory- Unexpected Response to Therapies
Rationale- The client is exhibiting symptoms of an anaphylactic reaction. The nurse should immediately discontinue the antibiotic, then check the vital signs and call for an order of diphenhydramine. There is no indication to initiate a code blue.
Subcategory- Unexpected Response to Therapies
The nurse has provided teaching to a client regarding prevention of bladder cancer. What statement by the client indicates the teaching was effective?
Rationale- Smoking cessation is important in prevention of bladder cancer. High calcium diets, urinary tract infections and lipid levels are not related to bladder cancer prevention.
Subcategory- Illness Management
Rationale- Smoking cessation is important in prevention of bladder cancer. High calcium diets, urinary tract infections and lipid levels are not related to bladder cancer prevention.
Subcategory- Illness Management
A client admitted to the emergency department has the following arterial blood gas values. PH 7.50. PaCO2 45 mmHg. HCO3 30 mEq/L. What causes should the nurse question the client about? Select all that apply.
Rationale – Vomiting and Cushing’s syndrome are two known causes of metabolic alkalosis which is demonstrated by the labs the client presented with. None of the other options would lead to metabolic alkalosis.
Subcategory – Alterations in Body Systems
Rationale – Vomiting and Cushing’s syndrome are two known causes of metabolic alkalosis which is demonstrated by the labs the client presented with. None of the other options would lead to metabolic alkalosis.
Subcategory – Alterations in Body Systems
A client diagnosed with shock has a blood pressure of 120/68, heart rate of 108 bpm respiratory rate of 25 breaths per minute and the ABGs demonstrate the PaCO2 of 28. The client is cold and clammy with the urine output of 20 mLs per hour. The client appears confused and slightly agitated. What stage of shock does the nurse suspect the client is in?
Rationale – Compensatory shock is the first stage where the client will normally having blood pressure within normal limits. The heart rate and respiratory rate would be elevated the client would have respiratory alkalosis. Their skin is cool and clammy with decreased urinary output. The client will often be confused you’re agitated. And progressive and irreversible shock of the client’s blood pressure would not be within normal limits.
Subcategory – Alterations in Body Systems
Rationale – Compensatory shock is the first stage where the client will normally having blood pressure within normal limits. The heart rate and respiratory rate would be elevated the client would have respiratory alkalosis. Their skin is cool and clammy with decreased urinary output. The client will often be confused you’re agitated. And progressive and irreversible shock of the client’s blood pressure would not be within normal limits.
Subcategory – Alterations in Body Systems
A client admitted with streptococcal pneumonia has it respiratory rate increase, tachycardia and shortness of breath. The chest x-ray reveals a parapneumonic pleural effusion. What action by the nurse is priority?
Rationale – Once the healthcare provider is able to assess and see the client a thoracentesis may be done; however, it is not priority when the client is first diagnosed. The nurse should continue to monitor the client. A new order for antibiotics will not be done until the pathogen is determined. A pleural effusion does not necessitate intubation.
Subcategory – Alterations in Body Systems
Rationale – Once the healthcare provider is able to assess and see the client a thoracentesis may be done; however, it is not priority when the client is first diagnosed. The nurse should continue to monitor the client. A new order for antibiotics will not be done until the pathogen is determined. A pleural effusion does not necessitate intubation.
Subcategory – Alterations in Body Systems
A client being weaned from a ventilator has the following vital signs blood pressure 132/72, heart rate 84, a respiratory rate 14, and oxygen saturation of 99%. What finding should result in the cessation of the weaning process?
Rationale – A client who is undergoing the weaning process who has a respiratory rate greater than 20 or less than eight should not be weaned. A heart rate increase of 20 bpm would necessitate termination of weaning. The blood pressure if greater than 20 mmHg increase systolic would result in termination of weaning. An oxygen saturation of less than 91 would result in termination of weaning.
Subcategory – Unexpected Responses to Therapies
Rationale – A client who is undergoing the weaning process who has a respiratory rate greater than 20 or less than eight should not be weaned. A heart rate increase of 20 bpm would necessitate termination of weaning. The blood pressure if greater than 20 mmHg increase systolic would result in termination of weaning. An oxygen saturation of less than 91 would result in termination of weaning.
Subcategory – Unexpected Responses to Therapies
A client that has just undergone open abdominal surgery for repair of an umbilical hernia just developed an opening of the wound with a small amount of intestine protruding. What actions should the nurse take immediately? Select all that apply.
Rationale – The nurse should cover the intestine with sterile saline soaked gauze and place the client and low Fowler’s position. It is not necessary to place oxygen on the client. An abdominal binder would be contraindicated after and evisceration has occurred. You should never press the intestine back into the wound.
Subcategory – Medical Emergencies
Rationale – The nurse should cover the intestine with sterile saline soaked gauze and place the client and low Fowler’s position. It is not necessary to place oxygen on the client. An abdominal binder would be contraindicated after and evisceration has occurred. You should never press the intestine back into the wound.
Subcategory – Medical Emergencies
A client diagnosed with pneumonia has been started on level floxacillin. Shortly after the IV was started the client begins itching wheezing and becomes irritable. What action should the nurse take first?
Rationale – The client is exhibiting signs of anaphylaxis. The first thing the nurse should do is stop the IV then contact the healthcare provider. The client should be maintained in an upright position not supine. The priority interventions will be to treat the reaction so that oxygen it may be effective.
Subcategory – Unexpected Response to Therapy
Rationale – The client is exhibiting signs of anaphylaxis. The first thing the nurse should do is stop the IV then contact the healthcare provider. The client should be maintained in an upright position not supine. The priority interventions will be to treat the reaction so that oxygen it may be effective.
Subcategory – Unexpected Response to Therapy
What methods are effective in delivering oxygen to the myocardium? Select all that apply.
Rationale – Nitroglycerin will help oxygen reach the myocardium as will providing oxygen. High Fowler’s position does not increase oxygenation. Digoxin and Lidocaine do not increase oxygenation.
Subcategory – Pathophysiology
Rationale – Nitroglycerin will help oxygen reach the myocardium as will providing oxygen. High Fowler’s position does not increase oxygenation. Digoxin and Lidocaine do not increase oxygenation.
Subcategory – Pathophysiology
The nurse has finished reviewing a shift report on the cardiac unit. What client should the nurse see first?
Rationale – A client that is receiving antibiotics for bacterial endocarditis reporting anxiety and itching is likely experiencing an allergic reaction to the antibiotic and should be seen immediately. The client with the cardiomyopathy with dyspnea should be seen but is not priority as this is a normal finding with hypertrophic cardiomyopathy. The client with the CABG surgery with an elevated temperature should be seen but is not priority over a client likely experiencing anaphylactic reaction to antibiotics. The client who had the cardiac catheterization that will be ambulating does not need to be seen immediately.
Subcategory – Physiological Adaptation
Rationale – A client that is receiving antibiotics for bacterial endocarditis reporting anxiety and itching is likely experiencing an allergic reaction to the antibiotic and should be seen immediately. The client with the cardiomyopathy with dyspnea should be seen but is not priority as this is a normal finding with hypertrophic cardiomyopathy. The client with the CABG surgery with an elevated temperature should be seen but is not priority over a client likely experiencing anaphylactic reaction to antibiotics. The client who had the cardiac catheterization that will be ambulating does not need to be seen immediately.
Subcategory – Physiological Adaptation
A client diagnosed with cardiomyopathy has received teaching regarding activity tolerance. What instructions by the nurse should be included in this teaching? Select all that apply.
Rationale – It is important to plan rest periods and have small frequent meals rather than large infrequent meals. The client should be encouraged to eat lean meats. They should not do too many activities at once. They should avoid alcohol.
Subcategory – Physiological Adaptation
Rationale – It is important to plan rest periods and have small frequent meals rather than large infrequent meals. The client should be encouraged to eat lean meats. They should not do too many activities at once. They should avoid alcohol.
Subcategory – Physiological Adaptation
A client is found unresponsive with no pulse. Ventricular tachycardia or is identified on the cardiac monitor. What procedure should the nurse prepare for?
Rationale – A client with ventricular tachycardia that has no pulse should be prepared for immediate defibrillation. Ablation is not a treatment for ventricular tachycardia. Pacemaker insertion is not indicated in a client with ventricular tachycardia. Synchronized cardioversion should not be done in a client that has no post.
Subcategory – Physiological Adaptation
Rationale – A client with ventricular tachycardia that has no pulse should be prepared for immediate defibrillation. Ablation is not a treatment for ventricular tachycardia. Pacemaker insertion is not indicated in a client with ventricular tachycardia. Synchronized cardioversion should not be done in a client that has no post.
Subcategory – Physiological Adaptation
What nursing interventions are priority for a client admitted to the emergency department with a diagnosis of myxedema coma?
Rationale – Fluid may be be administered however a close measurement of intake and output must be utilized to maintain a proper fluid balance. The client should not be rapidly warmed or externally warmed.
Subcategory – Illness Management
Rationale – Fluid may be be administered however a close measurement of intake and output must be utilized to maintain a proper fluid balance. The client should not be rapidly warmed or externally warmed.
Subcategory – Illness Management