Category 1
The nurse is caring for a client who is experiencing unresponsiveness following the administration of an opioid analgesic. The client has received a dose of naloxone but is currently difficult to arouse.
1. Reassess the client's level of consciousness.
2. Contact the client's health care provider (HCP).
3. Give the client supplemental oxygen per protocol.
4. Get a second dose of naloxone ready for administration.
5. Monitor the rate of the client's respirations.
6. Notify the unit manager immediately of the client's condition.
Correct
Reassess the client's level of consciousness.
It is appropriate for the nurse to reassess the client’s level of consciousness (LOC) based on the current data. Further decreases in LOC could indicate a need for additional intervention.
Correct
Contact the client's health care provider (HCP).
It is appropriate for the nurse to notify the client’s healthcare provider based on the current data as additional evaluation and prescriptions may be warranted.
Correct
Give the client supplemental oxygen per protocol.
It is appropriate for the nurse to administer supplemental oxygen per protocol for this client based on the current data. A lack of appropriate oxygen in the client’s blood could cause issues with arousal.
Correct
Get a second dose of naloxone ready for administration.
It is appropriate for the nurse to prepare a second dose of naloxone for administration as this medication has a half life of 60 to 90 minutes thus additional dosing may be required.
Correct
Monitor the rate of the client's respirations.
It is appropriate for the nurse to monitor the client’s rate of respirations and bradypnea is often an indicator of opioid toxicity which could require additional dosing of the naloxone.
Incorrect
Notify the unit manager immediately of the client's condition.
It is unnecessary for the nurse to notify the unit manager of the client’s condition based on the current data.
The nurse preceptor is observing a newly hired nurse provide care to a client who is being mechanically ventilated and has increased intracranial pressure (ICP). Which action by the newly hired nurse requires the nurse preceptor to intervene? Select all that apply.
Encourages visitors to speak softly and keep lights dimly lit.
Provides 100% oxygen before suctioning the endotracheal tube (ETT).
Hangs an intravenous (IV) bag of 0.45% sodium chloride (NS).
Performs minimal stimulation interventions when providing client care.
Suctions the endotracheal tube (ETT) for 20 seconds per pass every 30 minutes.
Correct
Hangs an intravenous (IV) bag of 0.45% sodium chloride (NS).
Half-strength normal saline is a hypotonic solution and should be avoided in trauma clients as the solution would cause water to shift from the extracellular fluid compartment to the intracellular compartment; therefore, this action by the novice nurse requires the nurse preceptor to intervene.
Correct
Suctions the endotracheal tube (ETT) for 20 seconds per pass every 30 minutes.
Suctioning is only recommended as needed and each pass should not exceed 10 seconds as prolonged suctioning can further increase the client’s ICP; therefore, this action by the novice nurse requires the nurse preceptor to intervene.
The nurse has provided the following SBAR report to the healthcare provider (HCP):
“The client in room 104 had an open appendectomy yesterday. The client’s pulse is rising at 145 beats per minute, temperature of 101.2° F, and systolic blood pressure has decreased to 76 mm Hg. I am concerned that the client is slipping into septic shock.”
Which critical information has been excluded by the nurse from the SBAR report?
A complete set of vital signs.
The time of initial onset of symptoms.
The client's past medical history.
A request for action.
A request for action.
The nurse has failed to make a recommendation or request for action based on the most recent client status change. For example, the nurse may have recommended a fluid bolus to address the client’s deteriorating blood pressure.
The nurse is teaching a client newly diagnosed with heart failure (HF) about the importance of exercise. Which information should the nurse include in the teaching plan? Select all that apply.
Choose a simple activity that you enjoy and gradually increase your activity level.
Plan to warm up and cool down so that you do not stop exercising abruptly.
Replace active exercise with stationary activities like deep breathing or meditation.
Plan to exercise during the time of day that you personally have the most energy.
Alternate periods of activity and exercise with designated periods of rest time.
Correct
Choose a simple activity that you enjoy and gradually increase your activity level.
Clients are more likely to continue exercising if they enjoy the activity. Examples may include taking a daily walk or working in the garden. Clients should start slowly and gradually increase their activity level as tolerance improves.
Correct
Plan to warm up and cool down so that you do not stop exercising abruptly.
Nurses should educate clients about the benefits of structuring their exercise. Clients should include time in their exercise plans to warm up and cool down adequately. Clients should not stop exercising abruptly.
Correct
Plan to exercise during the time of day that you personally have the most energy.
This technique allows the client to pair activities during the time of day that they feel the greatest amount of energy. Clients are less likely to want to exercise if they are tired. By analyzing which times that they most commonly experience greater energy or fatigue, clients may select a time during which they may be more likely to want to exercise.
Correct
Alternate periods of activity and exercise with designated periods of rest time.
By alternating periods of activity with periods of rest time, clients may be motivated to complete activity without risking exhaustion. Smaller periods of activity can provide manageable goals that clients can achieve. Planned periods of rest are equally as important to ensure that the body does not work too hard.
The nurse is caring for a client who is two days postpartum.
➤What factor(s) could increase the client’s risk for developing a postpartum infection? Select all that apply.
Vaginal delivery
Spontaneous rupture of membranes
Client history of asthma
Client history of diabetes
Internal fetal monitoring
Correct
Client history of diabetes
This answer is correct because a history of diabetes can increase a client’s risk for postpartum infection. In addition to increasing the likelihood of developing an infection, diabetes can also delay the healing process. Obesity, poor nutritional status, and a previous history of pelvic infections or bacterial vaginosis are other factors that may increase a client’s risk for developing a postpartum infection.
Correct
Internal fetal monitoring
This answer is correct because internal fetal monitoring can increase the client’s risk for developing postpartum infection. Internal fetal monitoring involves transducer placement on the fetal scalp directly through the cervix. While this type of fetal monitoring allows for closer and more reliable monitoring of fetal heart rate than external fetal monitoring, it does increase a client’s risk for infection (due to introduction of the foreign transducer).
The nurse is caring for a client who reports a positive home pregnancy test and the last menstrual period (LMP) was 3 months ago. The current date is December 8. Which statement by the nurse is correct?
"Your expected date of delivery is April 25."
"Your fundal height is normal at 12 cm below the symphysis pubis."
"You will likely experience urinary frequency."
"Based on your last menstrual period you should be experiencing quickening."
"I anticipate that you will have a positive Chadwick sign upon examination."
"You will likely experience urinary frequency."
"I anticipate that you will have a positive Chadwick sign upon examination."
The nurse is assessing a client with a head injury with signs and symptoms of syndrome of inappropriate antidiuretic hormone (SIADH).
Decreased urine output.
Elevated serum osmolality.
Elevated urine specific gravity.
Decreased serum osmolality.
Decreased serum sodium.
Correct
Decreased urine output.
Urine output is decreased for the client who experiences SIADH; therefore, the nurse anticipates this assessment finding.
Correct
Elevated urine specific gravity.
As antidiuretic hormone (ADH) continues to be secreted and water is retained, the client experiences a high specific gravity of the urine; therefore, the nurse anticipates this assessment finding.
Correct
Decreased serum osmolality.
Due to the increased total body water that is dilute, low serum osmolality is expected for the client who is diagnosed with SIADH; therefore, the nurse anticipates this assessing finding.
Correct
Decreased serum sodium.
Due to the increased total body water that is dilute, decreased serum sodium (i.e., dilutional hyponatremia) is expected for the client who is diagnosed with SIADH; therefore, the nurse anticipates this assessing finding.
The nurse is caring for a client who is admitted for the treatment of severe vomiting associated with hyperemesis gravidarum. The client has a specific gravity of 1.028. Which is the priority action by the nurse?
Assess skin turgor.
Notify the obstetrician.
Encourage oral fluid intake.
Document intake and output.
Correct
Assess skin turgor.
The client who experiences severe vomiting due to hyperemesis gravidarum is at risk for dehydration. A urine specific gravity that indicates concentrated urine requires monitoring for additional symptoms of dehydration.
The nurse is caring for a client newly diagnosed with polycythemia vera (PV) who has a hematocrit of 55%.
➤Which client statement is most concerning?
"I have pain in my calf when I try to get out of bed."
"The left side of my abdomen is tender to touch."
"I noticed when I got up this morning that I had been sweating."
"My vision has been blurry lately, I think that is causing headaches."
Correct
"I have pain in my calf when I try to get out of bed."
Increased blood thickness and decreased blood flow, as well as abnormalities in the platelets, increase the risk of blood clots; therefore, this client statement is concerning.
The nurse is providing discharge instructions to a client who was admitted to the medial-surgical unit due to an episode of heat stroke and sunburn. The nurse provides information about the risk factors related to melanoma.
Which client statement(s) indicates the need for additional teaching? Select all that apply.
"I should report any mole that changes color and/or shape."
"Melanoma can be pink, red, white, or blue like the flag."
"Most cases of skin cancer are discovered by dermatologists."
"Only young people who tan are at risk for skin cancer."
"Painless round moles are often skin cancer."
Correct
"Most cases of skin cancer are discovered by dermatologists."
This client statement indicates a need for additional teaching as skin cancer, or melanoma is often discovered by the individual and not a dermatologist.
Correct
"Only young people who tan are at risk for skin cancer."
This client response indicates a need for additional teaching as melanoma, or skin cancer is most likely to be diagnosed in clients over the age of 60 years.
Correct
"Painless round moles are often skin cancer."
This client statement indicates a need for additional teaching as melanoma, a form of skin cancer, is often irregular in shape and may itch; however, they rarely cause pain.
The nurse is caring for a client who is 32 weeks’ gestation and presents with painless vaginal bleeding. Which intervention should the nurse implement? Select all that apply.
Administer oxytocin.
Begin fetal monitoring.
Count perineal pad.
Initiate two 18-gauge peripheral intravenous (IV) catheters.
Perform a vaginal assessment.
Correct
Begin fetal monitoring.
Fetal monitoring is an appropriate intervention for the nurse to implement for the client who is 32 weeks’ gestation and presents with painless vaginal bleeding. Fetal monitoring allows the nurse to assess the fetal heart rate to determine if the fetus is experiencing distress.
Correct
Count perineal pad.
It is appropriate for the nurse to implement a peri-pad count to monitor the client’s bleeding and determine if there is a risk for hypovolemia and shock.
Correct
Initiate two 18-gauge peripheral intravenous (IV) catheters.
Inserting two large-bore IV catheters is an appropriate nursing intervention. The client may require IV fluid hydration and medication to halt the progression of labor.
The nurse manager is providing an educational inservice regarding violations of the Nurse Practice Act (NPA), which requires notification to the State Board of Nursing violations. Which example indicates a violation of this act? Select all that apply.
Complete an incident report.
Notify the healthcare provider (HCP).
Draw a serum blood glucose level.
Provide the client with a meal tray.
Ask the family why the pump was turned off.
Correct
Complete an incident report.
An incident report is required as the feeding is not infusing as prescribed; therefore, this is an appropriate nursing action.
Correct
Notify the healthcare provider (HCP).
It is important that the HCP be notified as additional prescriptions may be warranted; therefore, this is an appropriate nursing action.
Correct
Draw a serum blood glucose level.
A serum blood glucose level is needed to determine if the lack of feeding resulted in hypoglycemia which will likely require intervention for correction; therefore, this is an appropriate nursing action.
The nurse provides care for a client who is diagnosed with acute angle-closure glaucoma.
➤Which clinical manifestation should the nurse anticipate upon assessment? Select all that apply.
A decline in peripheral vision.
Central vision that is blurred.
Opacity of the optic lens.
Redness of the sclera.
Sudden intense eye pain.
Correct
Central vision that is blurred.
Acute angle-closure glaucoma blurs the central vision and causes halos in the vision due to swelling of the cornea; therefore, this is a finding that is anticipated by the nurse when assessing the client.
Correct
Redness of the sclera.
Acute angle-closure glaucoma causes redness of the sclera; therefore, this is an anticipated clinical manifestation for this client.
Correct
Sudden intense eye pain.
Acute angle-closure glaucoma causes sudden, intense pain to the affected eye due to intense pressure from fluid not draining properly within the eye; therefore, this is expected based on the client’s diagnosis.
The nurse is caring for a client newly diagnosed with macrocytic anemia.
➤Which type of diet is least appropriate for this client?
Low fat
Macrobiotic
Vegan
Vegetarian
Correct
Vegan
The vegan diet is devoid of all animal products, including meat, eggs and dairy,thus eliminating any food source of vitamin B12; therefore, this diet increases the risk for this type of anemia.
The nurse is caring for a client who has a cast on the right forearm following an injury 3 weeks prior.
➤Which statement indicates the need for further education?
“It helps to prop my casted arm on a pillow at night while sleeping.”
“Even though my arm itches, I am not sticking anything in the cast to scratch the itch.”
“Since my arm is heavy I am wearing an arm sling whenever I am not in bed.”
“I exercise my fingers in this arm at least once an hour to keep from getting stiff.”
Correct
“Since my arm is heavy I am wearing an arm sling whenever I am not in bed.”
This answer is correct because the statement “since my arm is heavy I am wearing an arm sling whenever I am not in bed” is a statement that requires further education. For the client that sustained an arm fracture, normal movement of the mobile joints is encouraged. This will assist in maintaining muscle strength and enhance bone healing and decrease risk related to the cast.
Which family member statement demonstrates the need for further education regarding the care of a client diagnosed with a stroke? Select all that apply.
"Because of the visual deficits on the affected side, I will approach my spouse from the unaffected side."
"I will encourage my spouse, who has one-sided weakness, to dress the stronger side of the body first."
"I will minimize any background noise when talking to my spouse due to the diagnosed receptive aphasia."
"I will remind my spouse who neglects one side to turn the head to properly survey the surroundings."
"I should expect my spouse to experience severe cognitive deficits due to the stroke."
Correct
"I will encourage my spouse, who has one-sided weakness, to dress the stronger side of the body first."
This statement indicates a need for additional teaching as the client is taught to dress the weaker side prior to the stronger side of the body when unilateral weakness occurs due to a stroke.
Correct
"I should expect my spouse to experience severe cognitive deficits due to the stroke."
This statement indicates the need for additional teaching as severe cognitive impairment is not anticipated; however, some behavioral changes may occur including a lack of impulse control in addition to a total lack of awareness of these deficits.
The nurse is completing a wellness assessment for a sleeping 3-month-old client.
➤Arrange the components of in the correct order. All options must be used.
51432
The proper order of the assessment for an infant is as follows:
5. Assessment of skin color and respiratory pattern is first because will do least disturbing to the baby first.
1. Listen to breath and heart sounds is best to do next because it is best to do when the baby is sleeping so these sounds can be heard.
4. Palpation of fontanelles and abdomen is next since it is a little more disturbing to the baby and a little more hands on.
3. Checking pupillary response will be a bright light and this will stimulate the baby more.
2. Induction of the Moro reflex is last since it can be very stimulating and in case it makes the baby cry.
The nurse is preparing to administer a vaccine to a 7-month-old infant. Which injection site and needle length is appropriate for the nurse to use?
Anterolateral thigh, 1-in (25-mm) needle.
Deltoid muscle, 3/8-in (9-mm) needle.
Ventrogluteal muscle, 5/8-in (16-mm) needle.
Vastus lateralis, 1.5-in (38-mm) needle.
Correct
Anterolateral thigh, 1-in (25-mm) needle.
The anterolateral thigh (i.e., vastus lateralis muscle) is the site of choice when administering an IM injection to an infant. In addition, the needle length is within the prescribed range for IM injection; therefore, this reflects an appropriate injection site and needle length for this client.
The nurse is caring for an elderly client with rheumatoid arthritis.
➤What nursing interventions should be implemented? Select all that apply.
Avoid application of barrier creams
Perform a comprehensive skin assessment
Utilize pressure relieving devices
Educate the client about pressure injury
Use an assessment tool to evaluate fall risk
Correct
Perform a comprehensive skin assessment
This answer is correct because conducting a comprehensive skin assessment provides the nurse with a detailed understanding of the client’s current skin status. A comprehensive skin assessment includes evaluation of the skin’s color, temperature, texture, moisture level, and turgor. The nurse should pay special attention to areas surrounding bony prominences.
Correct
Utilize pressure relieving devices
This answer is correct because utilizing pressure relieving devices helps to eliminate prolonged pressure that could result in a pressure injury over time. Pressure relieving devices may include special equipment like pressure-relieving mattresses, cushions, or padding. Skin care products may also be considered a pressure relieving device.
Correct
Educate the client about pressure injury
This answer is correct because education for clients helps to facilitate reduction of pressure injury. Education should include information about both client risk factors and prevention strategies. Clients are more likely to engage in activities to prevent pressure injuries if they understand their personal risks, along with the reasons and benefits that underscore preventative activities.
The nurse is providing education for a client prescribed calcitonin subcutaneous injection for the treatment of Paget’s disease.
➤Which statement should be included in the teaching?
“This drug will strengthen the bone and decrease bone bowing that occurs with this disease.”
“This drug will prevent the breakdown of bone that occurs with this disease.”
“This drug will help melt the bone as it breaks down because of this disease.”
“This drug will help relieve the pain of this disease by reducing bone reabsorption.”
Correct
“This drug will help relieve the pain of this disease by reducing bone reabsorption.”
This answer is correct because the statement “this drug will help relieve the pain of this disease by reducing bone reabsorption” is the benefit the nurse will provide for this drug. Calcitonin is a hormone that is prescribed for the treatment of pain related to Paget’s disease. This drug binds to osteoclast receptors which slows bone breakdown. The subcutaneous route has proven more successful than the nasal spray route.
The pediatric nurse is caring for a client who recently underwent surgical repair of tetralogy of Fallot.
A flat abdomen.
An increase in vomiting.
An increased amount of urine output.
Pale and cool hands, feet.
Periorbital edema.
Rapid weight gain.
Correct
Pale and cool hands, feet.
Pale, cool feet and hands is associated with decreased cardiac output and poor perfusion and is associated with heart failure.
Correct
Periorbital edema.
Periorbital edema is a clinical manifestation of heart failure due to venous congestion.
Correct
Rapid weight gain.
Rapid weight gain is clinical manifestation of heart failure due to venous congestion.
The nurse is assessing a 2-year-old client
➤Which developmentally-appropriate client actions are expected?
Select all that apply.
Client A: multipara, 5 cm dilation, history of treatment for morphine abuse.
Client B: multipara,10 cm dilation, ready to begin pushing, in the final stage of labor.
Client C: nullipara, 2 cm dilation, wants to walk the hallway to enhance labor progression.
Client D: nullipara, 8 cm dilation, reporting increased pain.
Client E: nullipara, 7 cm dilation, exhibiting significant grimacing during contractions.
Correct
Client D: nullipara, 8 cm dilation, reporting increased pain.
With a traditional opioid (e.g., morphine), as the laboring client continues receiving medication doses, the respiratory rate continues to decrease. The risk for respiratory depression decreases when nalbuphine hydrochloride is administered to laboring clients who are dilated up to 8 cm; therefore, the client can safely administer the prescribed medication.
Correct
Client E: nullipara, 7 cm dilation, exhibiting significant grimacing during contractions.
The laboring client may exhibit pain with consistent grimacing; therefore, a pain medication should be offered. This medication can be safely administered to this client.
The nurse is caring for a client who recently transferred from the intensive care unit (ICU) after undergoing coronary artery bypass graft (CABG) surgery. The client states, “the monitors beeped non-stop, and I was awake almost all night.” Which action should the nurse take to promote better sleep? Select all that apply.
Encourage the client to actively participate during physical therapy sessions.
Cluster nursing care to allow longer periods of uninterrupted time for sleep.
Withhold the client’s evening dose of diuretic to decrease wakefulness.
Ensure that the room lighting is bright during the day and dark at night.
Guide the client in deep breathing exercises prior to bedtime to increase relaxation.
Correct
Encourage the client to actively participate during physical therapy sessions.
Increased physical activity during the day can help clients feel tired and sleep more deeply at night. By encouraging the client to actively participate in physical therapy sessions during the day, the nurse promotes improved recovery and better sleep.
Correct
Cluster nursing care to allow longer periods of uninterrupted time for sleep.
Clustering nursing care allows the client to have longer periods of time for uninterrupted sleep. The hospital environment is one filled with activity and disruptions, so this intervention is essential to promote rest.
Correct
Ensure that the room lighting is bright during the day and dark at night.
Managing the environment is an important consideration to facilitate sleep. Proper lighting can help the body gain awareness of the time of day and underscore natural sleep cycles and routines.
Correct
Guide the client in deep breathing exercises prior to bedtime to increase relaxation.
Deep breathing exercises, prayer, or meditation are activities that may promote relaxation and help improve sleep during hospitalization. Music therapy and/or massage therapy may also facilitate relaxation.
The nurse is caring for several clients.
➤Which client(s) is at an increased risk for oral candidiasis? Select all that apply.
A client diagnosed with chronic emphysema who is on long-term corticosteroid therapy.
A client with a tongue ring who drinks two energy drinks a day.
A client who is diagnosed with pneumonia and prescribed high dose intravenous (IV) antibiotics
An older adult client with poor nutritional intake and dentures.
A client who is obese and taking a proton-pump inhibitor (PPI) for peptic ulcer disease (PUD).
Correct
A client diagnosed with chronic emphysema who is on long-term corticosteroid therapy.
A client with chronic emphysema who is on long-term corticosteroid therapy is at an increased risk of oral candidiasis. The oral and aerosol use of corticosteroid therapy increases the risk for this fungal infection
Correct
A client who is diagnosed with pneumonia and prescribed high dose intravenous (IV) antibiotics
A client receiving high dose IV antibiotics would be at an increased risk of oral candidiasis because antibiotics may alter the normal flora in the mouth.
Correct
An older adult client with poor nutritional intake and dentures.
This client has an increased risk for oral candidiasis due to poor nutritional intake and dentures.
The nurse is caring for a client with chronic emphysema to improve respiratory function.
➤Which type(s) of breathing are appropriate for this client? Select all that apply.
Correct
Diaphragmatic
This answer is correct because diaphragmatic breathing is a specific educational point the nurse will provide the client. When implementing this type of breathing, the client can better manage dyspneic events. This type of breathing decreases the amount of stale air in the lungs which helps the client manage dyspnea. This will assist in improving respiratory function for this client.
Correct
Abdominal
This answer is correct because abdominal breathing is a specific educational point the nurse will provide the client. When implementing this type of breathing, the client can better manage dyspneic events. This type of breathing decreases the amount of stale air in the lungs which helps the client manage dyspnea. This will assist in improving respiratory function for this client.
Correct
Pursed-lip
This answer is correct because pursed-lip breathing is a specific educational point the nurse will provide the client. When implementing this type of breathing, the client can better manage dyspneic events. This type of breathing decreases the amount of stale air in the lungs which helps the client manage dyspnea. This will assist in improving respiratory function for this client.