Deck 4: Fundamentals

Question 1

The unit implemented a quality improvement program to address client pain relief.  Which set of criteria is the best determinant that the goal has been met?

A)Chart audits found clients' self-reported pain scores improved by 10%
B)Number of narcotics used on the unit increased by 20%
C)Positive comments on returned client satisfaction surveys increased by 30%
D)Survey found that 90% of the nurses believed clients had better pain control

Answer 1

Chart audits found clients' self-reported pain scores improved by 10%

Question 2

A client with renal failure recently started dialysis and is unable to work due to ongoing health problems.  The client's spouse has started working for a cleaning service to replace the lost income.  The dialysis nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences when coming to dialysis.  Which is the most appropriate first response by the nurse?

A)"How is your spouse's new job going?"
B)"I notice that you seem frustrated."
C)"It can take time to adjust to dialysis. We have a support group that can be helpful."
D)"It's normal to be angry when you can't work any longer."

Answer 2

"I notice that you seem frustrated."

Question 3

A client is admitted to the hospital for chemotherapy complications.  Laboratory results show an absolute neutrophil count of 450 cells/mm³ (0.45 ×10⁹/L).  What information contained in the admission history of this client will need to be addressed during discharge education?

A)Eats steamed vegetables daily
B)Enjoys eating grilled shrimp weekly
C)Gardens as hobby
D)Takes a bath daily and applies moisturizer

Answer 3

Gardens as hobby

Question 4

An unlicensed assistive personnel (UAP) is aiding a client recovering from a right-sided cerebrovascular accident with resulting mild oropharyngeal dysphagia.  The client has been placed on a dysphagia diet.  Which actions require intervention by the registered nurse?  Select all that apply.

A)The UAP adds milk to mashed potatoes to make them thinner
B)The UAP encourages the client to occasionally turn the head to the left
C)The UAP helps the client sit in an upright position
D)The UAP places food on the strong side of the client's mouth
E)The UAP puts a straw in a fruit smoothie to prevent spilling

Question 5

Which client is at the greatest risk for development of hospital-acquired pressure injuries?

A)25-year-old client with quadriplegia, urosepsis, temperature of 101 F (38.3 C), and white blood cell count of 18,000/mm³ (18.0 x 10⁹/L)
B)50-year-old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb (9.1 kg) in a month, prealbumin level <10 mg/dL (100 mg/L), and mean arterial pressure of 50 mm Hg
C)80-year-old client 2 days post hip replacement with dementia, 2 Jackson-Pratt drains, and hemoglobin level of 14 g/dL (140 g/L)
D)87-year-old client 2 days post open cholecystectomy

Question 6

A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose.  What is the best response by the nurse?

A)"Have you shared your concerns with your health care provider (HCP)?"
B)"If I were you, I would be more worried about whether the melanoma has spread."
C)"Scar tissue formation is part of the natural healing process.  We will teach you how to care for your wound to minimize any complications."
D)"There is special make-up you can use to hide any facial scars left from the surgery."

Question 7

The nurse is teaching a client with insomnia about techniques to improve sleep habits.  Which statement by the client requires further teaching?

A)"I will avoid naps later in the day."
B)"I will keep the bedroom temperature cool."
C)"I will read in bed before trying to go to sleep."
D)"I will try to go to bed and wake up at the same time each day."

Question 8

A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer.  The client says to the nurse, "Is this disease going to kill me?"  What is the best response by the nurse?

A)"Hearing this diagnosis must have been difficult for you.  What are your thoughts?"
B)"We will do everything possible to prevent that from happening."
C)"Well, we're all going to die sometime."
D)"You should concentrate on getting better rather than thinking about death."

Question 9

The nurse teaches safety precautions of home oxygen use to a client with emphysema being discharged with a nasal cannula and portable oxygen tank.  Which client statement indicates the need for further teaching?  Select all that apply.

A)"I can apply Vaseline to my nose when my nostrils feel dry from the oxygen."
B)"I can cook on my gas stove as long as I have a fire extinguisher in the kitchen."
C)"I can increase the liter flow from 2 to 6 liters a minute whenever I feel short of breath."
D)"I should not polish my nails when using my oxygen."
E)"I should not use a wool blanket on my bed."

Question 10

The nurse is caring for an 83-year-old bedridden client experiencing fecal incontinence.  Which nursing intervention is the highest priority for this client?

A)Consult with the wound care nurse specialist
B)Insert a rectal tube to contain the feces
C)Provide perianal skin care with barrier cream
D)Use incontinence briefs to protect the skin

Question 11

An adult client has developed diarrhea 24 hours after the initiation of total enteral nutrition via nasogastric tube.  The client is receiving a hypertonic formula.  What is the bestnursing action?

A)Dilute the formula with water
B)Discontinue the tube feeding
C)Send a stool sample to the lab for culture and sensitivity
D)Slow the rate of administration of the feeding

Question 12

The nurse initiates prescribed intravenous (IV) therapy on an 86-year-old hospitalized client.  Which life span concept(s) should be considered when initiating IV therapy and caring for an older adult receiving IV therapy?  Select all that apply.

A)Avoid infusion devices in confused clients as alarms can be disruptive
B)Cardiac and renal changes may put the client at risk for hypervolemia
C)Older adults may have more fragile veins, increasing the risk of infiltration
D)Skin protectants and nonporous tape are helpful in reducing skin tears on fragile skin
E)Use a 30-45-degree angle on insertion because older adults have deeper veins that roll

Question 13

The nurse provides an in-service for hospital staff on how to prevent pressure injuries in clients with limited mobility.  Which instructions are appropriate for the nurse to include?  Select all that apply.

A)Apply moisture barrier cream to dry skin
B)Clean perineal area after incontinent episodes
C)Massage bony prominences frequently
D)Place foam-padded seat cushions on chairs
E)Reposition clients in bed every 6 hours

Question 14

The nurse is caring for a group of clients.  Which finding requires immediate action by the nurse?

A)Client scheduled for discharge who has had a peripheral IV in place for 84 hours
B)Client with a do-not-resuscitate prescription who has swelling at the IV site
C)Client with a saline lock who had a scheduled IV saline flush due 15 minutes ago
D)Client with an IV infusing at 20 mL/hr who has 100 mL fluid remaining in the bag

Question 15

The nurse admits an 81-year-old client with gastroenteritis.  Admission vital signs are temperature 101 F (38.3 C), blood pressure 90/42 mm Hg, pulse 118/min, and respirations 32/min.  Pulse oximetry shows 88%.  The nurse suspects which of the following factors may be affecting accuracy of the pulse oximetry reading?

A)Dehydration
B)Elevated temperature
C)Hypotension
D)Tachypnea

Question 16

A client has just returned to the room after having a mammogram.  The client is teary and in a shaky voice says to the nurse, "The radiology technician told me that it looks really bad - the tumor in my breast is very large."  Which is the best response by the nurse?

A)"I can see that you are very upset.  Let's talk about what happened."
B)"I'll report the technician to the head of the radiology department."
C)"The technician never should have said that to you."
D)"Your health care provider will discuss treatment options with you."

Question 17

The nurse is caring for a client with advanced Alzheimer disease.  Which techniques are appropriate when speaking with this client?  Select all that apply.

A)Ask open-ended questions
B)Face the client while speaking
C)Speak in a loud voice
D)Turn off the television and close the door
E)Use simple statements and questions

Question 18

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client?  Select all that apply.

A)Dimming the lights at night
B)Increasing the level of continuous IV sedation during nighttime hours
C)Leaving the television on for diversion at night
D)Opening the window blinds/shades in the morning
E)Scheduling interventions and activities during the day when possible
F)Turning off equipment alarms in the client's room at night

Question 19

The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone.  When the nurse asks about sodium intake, the client becomes angry and says, "I'm so tired of people telling me what to do!  I'm going to eat what I want, so leave me alone!"  Which of the following is the most appropriate response by the nurse?

A)"I can tell that you want me to go, so I will call in a few days to see how you are doing."
B)"I know you are frustrated with losing control of your life."
C)"It sounds like you are angry.  Tell me what's bothering you."
D)"Okay.  I'll just check your blood pressure and then go."

Question 20

A client of the Orthodox Jewish faith with a history of type 2 diabetes mellitus is hospitalized, recovering from a total right hip arthroplasty.  At noon, the client consumed a lean roast beef sandwich with lettuce and mustard, carrot and celery sticks, and fresh fruit.  What would be the most appropriate 2:00 PM snack for this client?

A)Angel food cake and fresh strawberries
B)Crackers and low-fat cheese
C)Hard-boiled egg and blueberries
D)Nonfat plain yogurt

Question 21

The client has a dislocated shoulder and the nurse is assisting the health care provider with bedside procedural moderate sedation (conscious sedation).  During the procedure, the client becomes restless and cries out "Help me!"  What action should the nurse take first?

A)Administer midazolam per protocol
B)Check the client's pulse oximeter
C)Give more morphine per protocol
D)Open the airway with head tilt-chin lift

Question 22

The nurse is caring for a 48-year-old executive on the cardiac unit who has just been diagnosed with primary hypertension.  Which teaching strategy implemented by the nurse is most likely to be effective for this client?

A)Leave diet pamphlets for the client to review at a later time
B)Refer the client to the nurse case manager to follow up with diet instructions
C)Sit with the client during meal selections and assist with identification of low sodium options
D)Turn the television on in the client's room to the patient education channel to watch

Question 23

A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer.  The client says to the nurse, "I'm so worried that my future spouse is going to call off our engagement."  What is the best response by the nurse?

A)"Are you concerned about how the surgery will affect your sexuality?"
B)"If you are concerned about infertility, you could always bank your sperm."
C)"The cancer is at an early stage.  You are going to be fine."
D)"What have you and your future spouse discussed about your condition?"

Question 24

A postoperative client with obesity and diabetes mellitus has an abdominal incision and is at risk for poor wound healing.  Which interventions should the nurse include in the plan of care to promote wound healing and prevent dehiscence?  Select all that apply.

A)Administer docusate PO daily
B)Administer ondansetron IV PRN for nausea
C)Apply an abdominal binder
D)Implement caloric restriction to promote weight loss
E)Monitor blood sugar to maintain tight glucose control

Question 25

The nurse is providing discharge instructions to a 70-year-old client newly diagnosed with heart failure who has a low literacy level.  What are some teaching strategies that the nurse can use for this client?  Select all that apply.

A)Conduct teaching sessions while a family member is present
B)Discourage the client from using the internet to look up health information
C)Have client watch a DVD about heart failure management
D)Print out pictures of a food label and review where to look for sodium content
E)Speak slowly and loudly so the client can understand you

Question 26

A client who is 24 hours postoperative bowel resection is receiving IV opioids PRN for severe pain.  The nurse reviews the health care provider's prescription to discontinue the continuous IV normal saline.  What is the nurse's most appropriate action?

A)Convert to a saline lock
B)Remove the IV catheter
C)Request a prescription for a saline lock
D)Slow the IV fluids to a keep-vein-open rate

Question 27

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash.  The client is undergoing cardiopulmonary resuscitation.  The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing.  Which is an example of the ethical principle of beneficence when responding to the client's family?

A)"He is critically ill and we are caring for his needs."
B)"His heart has stopped and we are attempting to revive him."
C)"I don't know how he is doing but you need to come."
D)"I will have the health care provider talk to you once you arrive."

Question 28

In which position would the nurse place a client recovering from a right modified radical mastectomy who is admitted from the post-anesthesia unit?

A)High-Fowler's position with the affected side's arm resting on the bed
B)Semi-Fowler's position with the affected side's arm on several pillows
C)Supine with the affected side's arm on several pillows
D)Supine with the affected side's arm resting on the bed

Question 29

A client with advanced multiple sclerosis (MS) has been a resident in a nursing home for the past 2 years.  One day, the client tells the nurse, "I want to get out of here and try living in my own home."  What is the best response by the nurse?

A)"Do you have family or friends who could take care of you?"
B)"I'll make a referral to the local home care agency in your area."
C)"It will be very difficult to manage your care at home."
D)"Tell me how you think your life would be different if you moved from here."

Question 30

A home health nurse is visiting a 72-year-old client who had coronary artery bypass graft surgery 2 weeks ago.  The client reports being forgetful and becoming teary easily.  How should the nurse respond?

A)"Don't worry.  You'll feel better in a few weeks."
B)"How well are you sleeping at night?"
C)"These symptoms can be common after major surgery.  It will take 4-6 weeks to completely heal and start to feel normal again."
D)"You may be experiencing depression.  I'll call the health care provider and see if we can get a prescription for an antidepressant."

Question 31

The registered nurse (RN) and licensed practical nurse (LPN) are caring for several clients.  The RN delegates client positioning to the LPN.  While evaluating the delegated task, the RN realizes that which client positions require intervention?  Select all that apply.

A)High Fowler position in preparation for a paracentesis
B)Left side-lying position after percutaneous liver biopsy
C)Semi-Fowler after cardiac catheterization via femoral entry
D)Sims during soap-suds enema administration
E)Supine position after a lumbar puncture

Question 32

A client is being discharged after having a coronary artery bypass grafting (CABG) x 5.  The client asks questions about the care of chest and leg incisions.  Which instructions should the registered nurse include?  Select all that apply.

A)Report any itching, tingling, or numbness around your incisions
B)Report any redness, swelling, warmth, or drainage from your incisions
C)Soak incisions in the tub once a week then clean with hydrogen peroxide and apply lotion
D)Wash incisions daily with soap and water in the shower and gently pat them dry
E)Wear an elastic compression hose on your legs and elevate them while sitting

Question 33

An elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization.  The next day, the client becomes agitated and says to the nurse, "I've got to get back home to my things.  I have so much to do."  Which is the most likely interpretation of this client's behavior?

A)The client has been admitted to the facility without the client's consent
B)The client is becoming delirious and should be assessed for infection
C)The client is concerned that someone might steal possessions
D)The client wants to take care of business before imminent death

Question 34

The client screams at the nurse, "You are all incompetent here!  I have been waiting for 2 hours!"  How should the nurse respond initially?

A)"I know you are upset, but I will have to call security if you continue to scream."
B)"I see that you are frustrated, but the delay cannot be avoided."
C)"It is upsetting to wait so long.  How can I best help you?"
D)"The wait is long today, but you will receive quality, unhurried care when it is your turn."

Question 35

The charge nurse in the telemetry unit has delegated the task of giving a bed bath to a male Arab client who practices traditional Islamic customs.  Which communication to the female nursing assistant demonstrates appropriate cultural sensitivity to this client?

A)"Ask the client's wife if she would like to give the bed bath."
B)"Do not make eye contact with the client during the bath."
C)"The client may prefer for you not to talk to him during the bath."
D)"Touching the head is a sign of disrespect; let the client wash his own face."

Question 36

The unlicensed assistive personnel (UAP) reports finding a reddened area on a client's sacrum during a bath.  What is the nurse's priority action?

A)Direct the UAP to apply a protective foam dressing
B)Document results of the Braden Scale in the electronic record
C)Notify the health care provider (HCP)
D)Perform an assessment on the client's skin

Question 37

The nurse answers a call light on a client not assigned to the nurse.  The client, who was just admitted from the emergency department, requests a cup of coffee.  What is the appropriate intervention?

A)Allow a family member to bring the client a cup of coffee from the cafeteria
B)Ask the client to wait until the health care provider's (HCP's) prescriptions can be verified
C)Delegate the task to the unlicensed assistive personnel (UAP) assigned to the client
D)Suggest water instead until admission assessment can be completed

Question 38

A client is scheduled for coronary artery bypass surgery in the morning.  In the middle of the night, the nurse finds the client wide awake.  The client demonstrates symptoms of extreme anxiety and tells the nurse about wanting to refuse the surgery.  Which statement by the nurse would be most appropriate?

A)"Please try not to worry, you have an excellent surgeon."
B)"Tell me about how you feel about your surgery."
C)"Why are you considering refusing the surgery?"
D)"You have the right to make your own decisions and can refuse the surgery."

Question 39

An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis.  The client becomes angry with the unlicensed assistive personnel (UAP), who is trying to help the client bathe.  Later, the UAP expresses frustration with the client to the registered nurse.  Which statement would be the most appropriate response?

A)"I'll talk with the client to see why the client is angry."
B)"It sounds like you shouldn't work with this client, so I will reassign you."
C)"Let's go together to ask about the client's concerns."
D)"Why don't you go talk with the client about why the client is angry?"

Question 40

An adult client is admitted with back pain and found to have a metastatic tumor on the spine.  The health care provider (HCP) explains that the client has few months to live and is likely to become totally paralyzed below the waist soon.  The next day, the client tells the nurse of wanting to be discharged despite the HCP's recommendation that the client stay a few more days.  Which is the most appropriate initial response by the nurse?

A)"I understand your desire to leave, but it would be very risky."
B)"I will ask the palliative care nurse to talk with you to help clarify your care goals."
C)"I will let the HCP know that you want to be discharged and do everything I can to make it happen."
D)"Tell me more about your need to leave the hospital."

Question 41

The nurse is caring for a client with a feeding tube that has become obstructed.  Which intervention should the nurse implement first to unclog the tube?

A)Flush and aspirate the tube with warm water
B)Instill a digestive enzyme solution into the tube
C)Instill cola or cranberry juice into the tube
D)Use a small-barrel syringe to flush the tube

Question 42

The nurse is preparing to irrigate the ears of a 67-year-old client with impacted cerumen.  Place the following steps for ear irrigation in the correct order.  All options must be used.

A)Assess the client for fever, ear infection, or tympanic membrane injury
B)Gently irrigate the ear canal with a slow, steady flow of solution
C)Place a towel and an emesis basin under the ear
D)Place the client in a sitting position with the head tilted toward the affected ear
E)Straighten the ear canal by pulling the pinna up and back

Question 43

The nurse is providing postmortem care for a client who has died after a long hospitalization.  The client had a do-not-resuscitate prescription in place at the time of death.  Which of the following interventions should the nurse include during postmortem care in preparation for transfer to the funeral home?  Select all that apply.

A)Allow family member to assist with care
B)Call the medical examiner for an autopsy
C)Gently close the client's eyes
D)Place a pad under the perineum
E)Remove the client's dentures

Question 44

The educator on a rehabilitation unit is teaching a graduate nurse (GN) about caring for clients who have had a stroke.  Which of the following statements by the GN indicate correct understanding of the teaching?  Select all that apply.

A)"Approach clients with visual impairment from the affected side when entering the room."
B)"Instruct clients with unilateral weakness to dress by donning clothes on the affected side first."
C)"Provide written instructions for activities of daily living to clients with receptive aphasia."
D)"Teach clients with left-sided neglect to turn their heads to scan the environment."
E)"Teach families of clients with right-sided stroke to expect impulsive behaviors."

Question 45

A legally blind client is being prepared to ambulate 1 day after an appendectomy.  What is the most appropriate action by the nurse?

A)Arrange for the client's service dog to come to the health care facility as soon as possible
B)Describe the environment in detail so the client can ambulate safely with a cane
C)Instruct the unlicensed assistive personnel to walk beside the client and lead by the hand
D)Walk slightly ahead of the client with the client's hand resting on the nurse's elbow

Question 46

The nurse is teaching a client of American Indian heritage how to self-administer insulin.  As the nurse describes the necessary steps in the injection process, the client continuously avoids eye contact and occasionally turns away from the nurse.  Which action is most appropriate for the nurse to take in this situation?

A)Continue teaching the client and verify understanding by return demonstration
B)Discuss how important it is for the client to pay attention during the teaching
C)Maintain eye contact during the teaching by following the client's movements
D)Provide written instructions and a private place for the client to learn independently

Question 47

The home health nurse is following up with the parent of a Native American infant recently diagnosed with lactose intolerance.  In accordance with principles of culturally competent care, what is the most important question for the nurse to ask the parent?

A)Do your other children have this condition?
B)How long did your infant have diarrhea?
C)How often are you feeding the infant?
D)What do you think caused your infant's illness?

Question 48

A Muslim woman is admitted to the inpatient trauma unit after falling and sustaining a head injury.  In providing culturally competent care for this client, which consideration is most important?

A)Allowing the client's husband to be with her during clinical examinations
B)Assigning the client to a private room
C)Ensuring that female health care workers are available to provide care to the client
D)Obtaining the services of a local Muslim imam

Question 49

The nurse is caring for a client newly prescribed crutches.  Which finding indicates the need for further teaching?

A)The axillary pads are torn and show signs of wear
B)The client has a 30-degree bend at the elbow when walking
C)The crutches and injured foot are moved simultaneously in a 3-point gait
D)There is a 3 finger-width space noted between the axilla and axillary pad

Question 50

A client is brought to the emergency department with multiple trauma injuries.  The nurse sees the client's Jehovah's Witness identification card.  As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following?  Select all that apply.

A)Epoetin alfa
B)Fresh frozen plasma
C)Homologous packed red blood cells
D)Normal saline
E)Platelet transfusion

Question 51

The charge nurse is instructing a new graduate nurse on performing postmortem care.  Which client situations might cause the nurse to delay or not perform postmortem care?  Select all that apply.

A)Client died following a prolonged illness
B)Client's family was not present when death occurred
C)Client's religious background requires special ceremonial treatment of the body
D)Death occurred in the emergency department following a suicide attempt
E)Family requests a priest to perform last rites

Question 52

The nurse is interviewing a non-English-speaking client.  Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency?  Select all that apply.

A)Address the interpreter directly
B)Ask the client's adult child to translate
C)Hold a pre-conference with the interpreter
D)Identify any gender or age preferences
E)Speak in short sentences

Question 53

A client on hospice home care is taking sips of water but refusing food.  Family members appear distressed and insist that the personal care worker "force feed" the client.  What is the priority nursing action?

A)Explain to the family that this is a normal physiological response to dying
B)Explore the family's thoughts and concerns about the client's refusal of food
C)Recommend a feeding tube
D)Tell the family that "force feeding" the client could cause the client to choke on the food

Question 54

A client calls the nurse to report exacerbation of chronic lower back pain after working in the yard all weekend.  Knowing that this worsened back pain is probably due to acute inflammation, the nurse recommends which nonpharmacologic intervention?

A)Heating pad
B)Positioning for comfort
C)Rest from pain-aggravating activities
D)Stretching exercises

Question 55

The family of a terminally ill, dying client verbalizes concern that the client is becoming dehydrated due to poor fluid intake.  When the family asks the nurse about administering IV fluids, the nurse's response is based on an understanding of which statement?

A)Providing artificial hydration at the end of life will make the client feel more comfortable
B)The decision whether to provide artificial hydration should consider client preferences and goals
C)The health care provider will prescribe artificial hydration when the client can no longer swallow
D)Withholding artificial hydration at the end of life speeds up the dying process

Question 56

Before examining the infant of a Mexican American mother, the nurse compliments the child's outfit.  The mother becomes visibly distressed.  What is the best next action for the nurse to take?

A)Ask the mother's permission to touch the child's hand
B)Interview the mother about the reason for bringing the child to the clinic
C)Reassure the mother that there is no reason for distress
D)Suggest postponing the examination until the mother calms down

Question 57

The community health nurse is preparing to teach a group of African American women about prevention of diseases common to their ethnic group.  Based on the incidence of disease within this group, which disorders should the nurse plan to discuss?  Select all that apply.

A)Cervical cancer
B)Hypertension
C)Ischemic stroke
D)Osteoporosis
E)Skin melanoma

Question 58

The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules.  The client states "I cannot take the medication in this form."  What is the nurse's first action?

A)Ask the health care provider to prescribe a different calcium channel blocker
B)Consult with the pharmacist to see if an alternate form of the drug is available
C)Open the capsule and sprinkle the medication in a cup of applesauce
D)Warn the client about the dangers of uncontrolled hypertension

Question 59

A nurse is caring for a client with blindness due to diabetic retinopathy.  Which interventions should the nurse implement for this client?  Select all that apply.

A)Ask a family member about the client's preferences for room arrangement
B)Offer the client an elbow to hold, and walk a half-step ahead for guidance
C)Say "goodbye" when leaving the room to help orient the client
D)Speak slowly and slightly louder so the client can understand
E)Use a clock-face pattern to explain food arrangement on the client's meal tray

Question 60

As the nurse begins to assist with ambulation of a 9-year-old who is one day post appendectomy, the child cries out, "It hurts too much.  I can't do it."  What is the first action by the nurse?

A)Administer an analgesic
B)Assess the child's level of pain using a numeric rating scale
C)Come back later in the day
D)Tell the child, "Get up and walk if you want to go home soon."

Question 61

A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases.  Which action is appropriate at this time?

A)Administer an inhaled bronchodilator
B)Check marked insertion depth of the tube
C)Request a prescription for a diuretic
D)Start the client on incentive spirometry

Question 62

The health care provider prescribes intravenous fluid resuscitation for a client in hypovolemic shock.  The nurse should anticipate the rapid infusion of which intravenous solution initially?

A)0)9% Sodium chloride
B)5% Albumin
C)Dextrose 5% and lactated Ringer's
D)Dextrose 5% and water

Question 63

The hospice nurse is providing end-of-life care to a client who is experiencing anorexia and cachexia.  Which interventions are appropriate?  Select all that apply.

A)Allow the client to refuse food if not feeling hungry
B)Ask if the client is experiencing any pain or nausea
C)Involve the client in meal planning and food selection
D)Plan for loved ones to share mealtimes with the client
E)Provide oral care before and after meals to alleviate dry mouth

Question 64

The nurse will anticipate administration of isotonic IV fluids in which clients?  Select all that apply.

A)14-day-old client has urine output of 2 mL/kg/hr with flat fontanel
B)3-month-old client with diarrhea has a capillary refill of 4 seconds and mottling in lower extremities
C)8-year-old client has serum sodium of 131 mEq/L (131 mmol/L) and blood urea nitrogen of 15 mg/dL (5.4 mmol/L)
D)Client is having contractions every 10 minutes and will be receiving an epidural analgesic
E)Client received a bolus of IV fluid for hyperemesis gravidarum, and urine output is 80 mL/4 hr and pulse is 120/min

Question 65

A nurse is caring for a client who is meeting with the palliative care team.  After the meeting, the client's family asks for clarification about palliative care.  Which statements about palliative care are accurate?  Select all that apply.

A)Palliative care focuses on quality of life and can be provided at any time
B)Palliative care is only possible with a terminal diagnosis of ≤6 months
C)Palliative care is provided by a multidisciplinary team
D)Palliative care is another term for hospice care
E)Palliative care provides relief from symptoms associated with chronic illnesses

Question 66

A client is undergoing chest tube placement in the emergency department after being involved in a motor vehicle collision.  The client's spouse arrives and demands to be with the client.  Which action should the nurse take?

A)Allow the spouse in the room, out of the way of care providers, and explain the events occurring with the client
B)Assist the spouse in observing outside the room through a window and have a chaplain explain the care being provided
C)Explain the client's condition, but inform the spouse that entering the room is not allowed until the client is stabilized
D)Inform the spouse that being in the room during procedures is unsafe for the client, and escort the spouse to the waiting area

Question 67

The nurse is reviewing a client's preoperative questionnaire, which indicates a religious preference with spiritual needs concerning surgery scheduled later today.  Which action is most appropriate at this time?

A)Ask the client when a spiritual leader or clergy member is coming to visit
B)Document the response and notify the health care provider and perioperative team
C)Follow up with the client regarding the nature of the spiritual needs or religious practices
D)Notify the hospital chaplain and tell the client that the chaplain will come by to assist

Question 68

The nurse is caring for 4 clients requiring IV fluid therapy.  For which client should the nurse anticipate the need for isotonic crystalloid administration?

A)25-year-old with a closed-head injury and signs of increasing intracranial pressure
B)45-year-old with acute gastroenteritis and dehydration
C)60-year-old with seizures and serum sodium of 112 mEq/L (112 mmol/L)
D)68-year-old with chronic renal failure and hypertensive crisis

Question 69

The nurse is caring for a hospitalized client with an acute exacerbation of heart failure.  The client receives digoxin 0.5 mg PO once daily, furosemide 40 mg PO twice daily, and potassium chloride (KCl) 20 mEq PO twice daily.  The client's child reports that the client has trouble swallowing the large KCl pill.  The client's potassium level is 3.7 mEq/L (3.7 mmol/L).  What action should the nurse take first?

A)Consult with the pharmacist to see if other oral forms of KCl are available
B)Crush the pill and mix it with applesauce or pudding
C)Hold the KCl until the health care provider makes rounds
D)Instruct the client to tuck the chin to the chest when swallowing the pill

Question 70

The registered nurse (RN) is providing nursing care with a licensed practical nurse and unlicensed assistive personnel.  The RN administers hydromorphone 1.5 mg IVP per STAT order to a client with severe abdominal pain.  Three hours later, the client rates pain as a 9 on a scale of 0-10 and requests pain medication.  What is the most appropriate action for the RN to take?

A)Administer the hydromorphone
B)Ask the licensed practical nurse to administer the medication
C)Ask the unlicensed assistive personnel to take repeat vital signs
D)Contact the health care provider

Question 71

The pediatric clinic nurse reinforces culturally competent care at an in-service.  Which finding would be inappropriate to include as a common dermatologic effect of alternative medicine therapies?

A)Blisters with a garlic scent near the wrists
B)Circular bruised blemishes on the back
C)Markings appearing to be human bites on the arms
D)Welt-like linear lesions on the back

Question 72

A client is being seen in the clinic after receiving an external breast prosthesis after a mastectomy.  What question from the nurse best evaluates the effectiveness of the prosthesis on body image?

A)"Do you feel you are able to engage in sexual activity with your prosthesis?"
B)"Do you wear the prosthesis all the time or only when out of the home?"
C)"How do you cope with feelings of self-consciousness?"
D)"Since receiving your prosthesis, how do you see yourself differently?"

Question 73

The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness.  The client is flushed, sweating, nauseated, and slightly tachycardic.  Which action is most appropriate at this time?

A)Call emergency medical services and place ice packs on the client's axilla and groin
B)Encourage the client to leave the venue to visit a health care provider
C)Evaluate whether the client may be intoxicated
D)Move the client to an air-conditioned booth and provide a cool sports drink

Question 74

The nurse plans to administer 9:00 AM medications via the nasogastric (NG) route to a client with an NG tube.  The nurse contacts the primary health care provider (PHCP) to clarify which prescriptions that are contraindicated using this route?  Select all that apply.

A)Enteric-coated ibuprofen 200-mg tablet
B)Extra-strength acetaminophen 500-mg tablet
C)Metoprolol extended-release 50-mg tablet
D)Sulfamethoxazole double-strength 800-mg tablet
E)Tamsulosin 0.4-mg slow-release capsule

Question 75

The nurse is caring for a client with partial hearing loss.  Which interventions would be appropriate to promote effective communication?  Select all that apply.

A)Dim lights to prevent overstimulation
B)Post a hearing impairment sign on the client's door
C)Raise voice to speak more loudly
D)Speak directly facing the client
E)Tell family to take hearing aids home so they will not be lost

Question 76

When assessing the client's pain level, what will the nurse determine is the most reliable indicator of the pain?

A)Client's ethnic background
B)Client's report of symptoms
C)Client's vital signs
D)Extent of client's injury

Question 77

The nurse working in an extended care facility transcribes a prescription from the health care provider for a single daily dose of 150 mg of ranitidine; this is to be taken orally at bedtime for treatment of gastroesophageal reflux disease.  Of the following prescriptions, which one is transcribed correctly?

A)Ranitidine 150 mcg daily by mouth
B)Ranitidine 150 mg per os qhs
C)Ranitidine 150 mcg po qd nightly
D)Ranitidine 150 mg PO at bedtime

Question 78

A home health nurse visits a client with Alzheimer disease.  The caregiver appears frustrated and reports that the client has been persistently restless and agitated.  Which nursing action is the priority at this time?

A)Ask about the client's recent bowel and bladder habits
B)Assess the home for sources of excessive noise
C)Provide information about respite and adult day care
D)Review behavior-management techniques with caregiver

Question 79

The nurse enters a client's room and finds that the client and spouse are crying.  The spouse states that the health care provider just diagnosed the client with Alzheimer disease.  What is the best response by the nurse?

A)"Do you have any questions about the diagnosis?"
B)"There are medications available to treat Alzheimer disease."
C)"This new diagnosis must be frightening for you."
D)"We can help you make decisions about your care."

Question 80

The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer.  Which of the following interventions would the nurse anticipate for this client?  Select all that apply.

A)Arrange for health care workers of the same sex to provide care for the client
B)Coordinate with the registered dietician to provide halal meals
C)Reposition the immobile client to face the city of Mecca during daily prayer times
D)Restrict the number of visitors from the family to preserve the client's privacy
E)Upon death, provide the family with supplies for postmortem care