A
A nurse is reviewing laboratory values for a client. Which of the following findings indicates the presence of an infection?
A. Hgb 15 g/dL
B. Platelet count 200,000/mm3
C. WBC count 22,000/mm3
D. Creatine kinase 75 units/L
C. WBC count 22,000/mm3
A nurse is preparing to administer an enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?
A. Check the client's medical record for the provider's prescription.
B. Explain to the client that the provider prescribed the procedure.
C. Assure the client that enemas are commonly prescribed for constipation.
D. Inform the charge nurse that the client refused the enema.
A. Check the client's medical record for the provider's prescription.
A nurse is caring for a confused patient. Which should the nurse do to prevent this patient from falling?
A. Maintain close supervision
B. Reinforce how to use the call light
C. Place the patient in a room near the nurses’ station
D. Encourage the patient to use the corridor handrails
C. Place the patient in a room near the nurses’ station
A nurse is obtaining a health history for a client's comprehensive physical examination. After inspecting the client's abdomen, which of the following skills of the physical examination process should the nurse perform next?
A. Percussion
B. Palpation
C. Auscultation
D. Olfaction
C. Auscultation
The nurse is assessing the lower extremities for edema. Which of the following is the correct technique for grading edema?
A. Using a Doppler to assess blood flow
B. Pressing the skin and observing how long it takes for the indentation to disappear
C. Measuring calf circumference with a tape measure
D. Palpating the pulses and comparing them bilaterally
B. Pressing the skin and observing how long it takes for the indentation to disappear
During the insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurse’s arm. Which of the following actions should the nurse take?
A. Obtain a new catheter and reattempt insertion
B. Continue with the catheter insertion
C. Soak the catheter in chlorhexidine for 15 min and then reattempt insertion
D. Wipe the catheter with povidone-iodine and continue the catheter insertion
A. Obtain a new catheter and reattempt insertion
A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?
A. A reddened area over the sacrum
B. Stiffness in the lower extremities
C. Difficulty moving the upper extremities
D. Difficulty hearing some types of sounds
A. A reddened area over the sacrum
A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications?
A. Pressure injury
B. Pulmonary embolism
C. Pneumonia
D. Diarrhea
C. Pneumonia
Clients who have dysphagia are at risk for aspiration pneumonia. The nurse should monitor the client for fever and adventitious breath sounds.
A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?
A. "Information about a client can be disclosed to family members at any time."
B. "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form."
C. "A client's address would be an example of personally identifiable information."
D. "HIPAA is a federal law, not a state law."
A. "Information about a client can be disclosed to family members at any time."
A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?
A. Gown
B. Gloves
C. Face shield
D. Mask
B. Gloves
A nurse on a medical-surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client’s bedside at all times?
A. Neck brace
B. Blankets
C. Tongue blade
D. Suction Equipment
D. Suction Equipment
A nurse is caring for a client who starts to experience a seizure while sitting in a chair. Which of the following actions should the nurse take?
A. Restrain the client
B. Seek the help of a coworker and lift the client back into bed
C. Place a padded tongue blade in the client’s mouth
D. Lower the client to the floor and place a pad under the client’s head
D. Lower the client to the floor and place a pad under the client’s head
A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?
A. Remove the restraint every 3 hours
B. Ensure 3 fingers fit beneath the restraints
C. Secure the restraint to the side rails
D. Renew the prescriptions for the use of restraints within 24 hours
D. Renew the prescriptions for the use of restraints within 24 hours
A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching?
A. "I will need to wipe my perineal area from back to front after urination."
B. "I will need to empty my bladder regularly and completely."
C. "I will need to drink apple cider vinegar each day."
D. "I need to drink 8 cups of liquid each day."
A. "I will need to wipe my perineal area from back to front after urination."
A nurse is inserting an NG tube for a client. Which of the following actions should the nurse take?
A. Wear sterile gloves to insert the NG tube.
B. Determine the length of the NG tube to be inserted prior to the procedure.
C. Place the client into a left lateral position before inserting the NG tube.
D. Ask the client to cough while inserting the NG tube.
B. Determine the length of the NG tube to be inserted prior to the procedure.
A nurse is providing discharge education to a client diagnosed with fluid volume excess (FVE) due to liver failure. Which of the following meal options should the nurse recommend for the client?
A. Spaghetti and with commercial red sauce
B. Bowl of ice cream
C. Canned soup
D. Baked chicken breast
D. Baked chicken breast
A nurse is teaching a newly licensed nurse about maintaining correct posture when transferring clients. Which of the following statements should the nurse make?
A. "Loosen your abdominal muscles."
B. "Tilt your head toward your chest."
C. "Keep your back straight."
D. "Keep your knees straight."
C. "Keep your back straight."
The nurse should keep their back straight to support the spine and reduce the risk of injury.
A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make?
A. "Lie on your side with your top arm resting on the bed and your weight on your hip."
B. "Have a table beside your bed so you can sit on the bedside and rest your arms on the table."
"Have your head turned to the side when you lie on your stomach."
"Lie on your back with your head and shoulders supported by a pillow."
B. "Have a table beside your bed so you can sit on the bedside and rest your arms on the table."
A nurse is assessing a client for manifestations of pain. Which of the following findings is an objective indicator of pain?
A. The client states the pain is located on their abdomen.
B. The client rates their pain as an 8 on a scale of 0 to 10.
C. The client reports a burning sensation.
D. The client grimaces when they move.
D. The client grimaces when they move.
A nurse is preparing a client for a colonoscopy. The client has a family history of colon cancer. Which of the following types of prevention is the nurse demonstrating?
A. Quaternary
B. Tertiary
C. Primary
D. Secondary
D. Secondary
The nurse is demonstrating secondary prevention. Secondary prevention is providing care to detect a health condition, such as colon cancer.
A nurse is teaching about delegation with a newly licensed nurse. Which of the following statements if made by the newly licensed nurse indicates understanding?
A. “The nurse manager is responsible for delegating nursing tasks during each shift.”
B. “It is the duty of the delegatee to perform a task without asking questions when it is delegated.”
C. “I am responsible for ensuring that a delegated task is completed.”
D. “There are 4 rights of delegation.”
C. “I am responsible for ensuring that a delegated task is completed.”
A nurse is teaching a newly licensed nurse about pain. Which of the following is an example of acute pain?
A. Fibromyalgia
B. Peripheral neuropathy
C. Surgical incision
D. Rheumatoid arthritis
C. Surgical incision
A surgical incision causes a short-term, anticipated pain that lasts less than 6 months.
A nurse administers the wrong medication to a client. Which of the following actions should the nurse take first?
A. Document the client's condition in the electronic medical record.
B. Fill out an incident report.
C. Notify the provider.
D. Check the client's vital signs.
D. Check the client's vital signs.
A nurse is providing discharge teaching to an older adult about home safety. Which of the following statements by the client indicates an understanding of the teaching?
A. “I will secure any wires in my home under rugs.”
B. “I will put on socks when I get out of bed.”
C. “I will put a night-light in the hallway.”
D. “I will have the steps to my house painted a dark color.”
C. “I will put a night-light in the hallway.”
A nurse is preparing to transfer a client to a long-term care facility. Which of the following actions should the nurse take to ensure a safe transfer?
A. Verify that the client has received all of their medications
B. Give the client a copy of their discharge summary
C. Arrange transportation for the family members to the new facility
D. Provide a detailed verbal report to the receiving nurse
D. Provide a detailed verbal report to the receiving nurse
A nurse is preparing to witness informed consent for a client who is preoperative. The client asks the nurse, "Are there other options besides surgery?" Which of the following responses should the nurse make?
A. "It is time to sign the consent so your treatment can begin."
B. "I would not have this type of surgery if I were you."
C. "Have you discussed other treatments with your provider?"
D. "I can inform the surgeon you do not want the surgery."
C. "Have you discussed other treatments with your provider?"
A nurse is evaluating teaching with a client who reports insomnia. Which of the following client statements indicates an understanding of the teaching?
A. "I will watch television in my bedroom before I go to sleep."
B. "I will go to bed at the same time, even if I am not tired."
C. "I will stop exercising at least 2 hr before bedtime."
D. "I will take a 1 hr nap each day."
C. "I will stop exercising at least 2 hr before bedtime."
The client should exercise regularly. However, the client should stop exercising at least 2 hr before bedtime to promote sleep.
A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury?
A. A client who is receiving enteral feeding and can change position independently.
B. A client who makes frequent slight changes in position and walks occasionally.
C. A client who is unresponsive to verbal commands and changes position occasionally.
D. A client who alert and responsive and eats 25% of each meal.
C. A client who is unresponsive to verbal commands and changes position occasionally.
A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse committed?
A. Battery
B. Negligence
C. Invasion of privacy
D. Assault
B. Negligence
Negligence is the failure to provide the expected standard of care. The expected standard of care was strict bedrest.
A nurse is caring for a client who has a Clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take?
A. Place the client on complete bed rest
B. Wear a mask when assisting the client with his meal tray
C. Use alcohol-based sanitizer to cleanse the hands
D. Wear gloves when changing the client’s gown
D. Wear gloves when changing the client’s gown
A nurse is caring for a client who recently had a stroke. The client requires assistance with strengthening the affected side. Which of the following referrals should the nurse anticipate the provider to make?
A. Social worker
B. Respiratory therapist
C. Occupational therapist
D. Physical therapist
D. Physical Therapist
The nurse anticipates the provider to prescribe a referral a physical therapist for the client. Referrals and consultations are part of the collaborative process incorporating different health care team members. The physical therapist assists the client to improve their strength and movement on the affected side due to the stroke.
A nurse is caring for a client who has a fractured femur and a blood pressure of 140/94 mm Hg. Which of the following actions should the nurse take first?
A. Return in 30 min to recheck the client's blood pressure.
B. Instruct the client about a low-sodium diet.
C. Ask the client if they are having pain.
D. Request a prescription for an antihypertensive medication.
C. Ask the client if they are having pain.
A nurse is assessing a client who has an oral temperature of 39° C (102.2° F). Which of the following findings should the nurse expect?
A. Decreased peripheral pulses
B. Heart rate 108/min
C. Dilated pupils
D. Respiratory rate 10/min
B. Heart rate 108/min
A heart rate of 108/min is greater than the expected reference range of 60 to 100/min. A fever causes an increase in metabolic demands and an increased heart rate.
During a mass casualty event, a nurse is assigned to triage patients. Which patient should be prioritized for immediate treatment based on the principles of triage?
A. A patient with a sprained ankle and slight bleeding
B. A patient with a small laceration and a headache
C. A patient with severe chest pain and difficulty breathing
D.A patient with a broken arm and minor abrasions
C. A patient with severe chest pain and difficulty breathing
A nurse is transferring a client to the surgical unit postoperatively. During the handoff report, the nurse states that "Dr. Jones performed a bowel resection." Which section of the SBAR communication tool does this statement address?
A. Background
B. Recommendation
C. Situation
D. Assessment
C. Situation
The situation section of the SBAR communication tool includes why the client is in the hospital. Information might encompass introductions and surgical procedures performed.
A nurse is assessing a client who sustained a head injury. The client's right pupil is 6 mm and does not react to light, while the left pupil is 3 mm and reactive. What is the appropriate action?
A. Administer prescribed pain medication
B. Perform a visual acuity test
C. Notify the healthcare provider immediately
D. Document the findings as normal
C. Notify the healthcare provider immediately
While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first?
A) Complete an incident report.
B) Request the risk manager obtain consent for HIV testing from the client.
C) Wash the site of injury with soap and water.
D) Consent to postexposure treatment with antiretroviral medications.
C) Wash the site of injury with soap and water.
Answer Rationale:
The greatest risk to the nurse is infection transmission; therefore, the nurse should first wash the area with soap and water to reduce the risk of transmission.
A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?
1) Turn the client's head to the side.
2) Check the client's motor strength.
3) Loosen the clothing around the client's waist.
4) Document the time the seizure began.
1) Turn the client's head to the side.
Answer Rationale:
The first action the nurse should take when using the airway, breathing, circulation approach to client care is to turn the client's head to the side. This action keeps the client's airway clear of secretion to prevent aspiration.
A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply.)
A. Verify the oxygen flow rate every other day.
B. Check the cannula position on a regular basis.
C. Check the tops of the ears for skin breakdown.
D. Post “no smoking” signs in a prominent location in the home.
E. Apply petroleum ointment to nares if they become dry and irritated.
B. Check the cannula position on a regular basis.
C. Check the tops of the ears for skin breakdown.
D. Post “no smoking” signs in a prominent location in the home.
A nurse is assessing a patient with hypervolemia. Which of the following signs and symptoms is most consistent with this condition?
A) Weak pulse, hypotension, and confusion.
B) Weight loss, tachypnea, and dry mucous membranes.
C) Jugular vein distention, edema, and crackles in the lungs.
D) Tachycardia, cool extremities, and decreased urine output.
Answer: C) Jugular vein distention, edema, and crackles in the lungs.
Rationale: Hypervolemia (fluid overload) typically presents with signs such as jugular vein distention, peripheral edema, and pulmonary crackles due to fluid retention and impaired gas exchange in the lungs.
A nurse is preparing to admit a client who has a new diagnosis of methicillin-resistant Staphylococcus aureus (MRSA). The nurse should plan to place the client in which of the following types of transmission-based precautions?
A. Protective
B. Airborne
C. Contact
D. Droplet
C. Contact
A client newly admitted for a myocardial infarction. Appropriate activities to assign to assistive personnel (AP) would include all the following except:
A. Reporting to the nurse that the patient complained of chest pain
B. Teaching about what foods are high in sodium
C. Assisting with ambulation to the restroom
D. Recording input & output
B. Teaching about what foods are high in sodium
AP's should not teach clients
A charge nurse is providing an in-service to a group of nurses on the different levels of illness prevention. The nurse should include which of the following as an example of secondary prevention?
A. A client who is asymptomatic is not scheduled for a series of tests.
B. A client who has heart failure is scheduled for an echocardiogram.
C. A client is scheduled to receive an influenza vaccination.
D. A client who has a family history of breast cancer is scheduled for a mammogram.
D. A client who has a family history of breast cancer is scheduled for a mammogram.
A client who has a family history of breast cancer and is scheduled for a mammogram is an example of secondary prevention. Secondary prevention is early detection of a disease before it progresses. Secondary prevention can include screenings and other forms of diagnostic tests.
A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply).
A. Hypertension
B. Confusion
C. Bradycardia
D. Tachypnea
E. Restlessness
A. Hypertension
B. Confusion
D. Tachypnea
E. Restlessness
The nurse is auscultating heart sounds at the Apex of the heart. What is the correct location to hear the apical pulse?
A. Second intercostal space, right sternal border
B. Fourth intercostal space, left sternal border
C. Fifth intercostal space, left mid-clavicular line
D. Second intercostal space, left sternal border
C. Fifth intercostal space, left mid-clavicular line
A nurse is providing teaching to a client about manifestations of pulmonary embolism (PE). Which of the following findings should the nurse include in the teaching? (Select All That Apply)
A. Difficulty speaking
B. Bloody sputum
C. Facial weakness that worsens at night
D. Shortness of breath
E.Chest pain that worsens with deep breathing
B. Bloody sputum
D. Shortness of breath
E.Chest pain that worsens with deep breathing
A nurse is assessing a client who reports insomnia. Which of the following findings can contribute to the client's insomnia? (Select all that apply)
A. Morning walk
B. Alcohol intake
C. Warm bath
D. Stress
E. Irregular schedule
B. Alcohol intake
D. Stress
E. Irregular schedule
An assistive personnel (AP) tells the nurse manager that she observed a nurse on the unit removing a small amount of morphine from syringes prior to administering the medication to clients. Which of the following actions should the nurse manager take first?
1) Gather data about the nurse’s work performance and attendance history.
2) Approach the involved nurse to discuss the behavior.
3) Notify the risk manager.
4) Refer the nurse to the board of nursing diversion program.
1) Gather data about the nurse’s work performance and attendance history.
Answer Rationale:
The first action the nurse should take is to conduct an investigation and determine if the allegations are true.
A nurse is reviewing a patient's laboratory results, which include a magnesium level of 1.1 mg/dL. The nurse should monitor for which of the following signs of hypomagnesemia?
A) Shallow respirations and muscle weakness.
B) Positive Trousseau’s sign and abdominal cramping.
C) Hypertension and hyperreflexia.
D) Hyperactive deep tendon reflexes and tremors.
Hypomagnesemia often presents with hyperactive deep tendon reflexes, tremors, and muscle cramps. It can also cause neuromuscular irritability and seizures in severe cases.
A patient has been diagnosed with hyperkalemia. The nurse would expect the following clinical findings:
A) Muscle weakness, fatigue, and arrhythmias.
B) Increased deep tendon reflexes, hyperreflexia, and tremors.
C) Dry mucous membranes, poor skin turgor, and confusion.
D) Bradycardia, hypotension, and muscle cramps.
A) Muscle weakness, fatigue, and arrhythmias.