A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is beingachieved.
A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is beingachieved.
a. Number of staff inducedinjury
b. Client satisfactionsurvey
c. Health care-associated infectionrate.
d. Rate of needle-stick injuries bynurse.
2. The nurse is preparing to assist a newly admitted client with personal hygiene measures. The client…the client’s gag reflex. Which action should the nurseinclude?
A. Offer smalls sips of water through astraw
B. Place tongue blade on back half oftongue
C. Use a penlight to observe back of oralcavity
D. Auscultate breath sounds after clientswallows
3. The father of an 11-year-oldboy….
4. The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinineclearance.
A. Assess the client for confusion and reteach theprocedure
B. Check the urine for color andtexture
C. Empty the urinal contents into the 24-hour collectioncontainer
D. Discard the contents of theurinal
5. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most
A. Ask her how she would like to participate in the client’scare
B. Provide the wife with information abouthospice
C. Encourage the wife to visit after painful treatments arecompleted
D. Refer her to support group for family members of those dying ofcancer
6. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurserecommend?
A. Plan low carbohydrate and high proteinmeals
B. Engage in strenuous activity for an hourdaily
C. Keep a record of food and drinks consumeddaily
D. Participated in a group exercise class 3 times aweek
7. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurseobserve?
A. Tops of theear
B. Bridge of thenose
C. Around thenostrils
D. Over thecheeks
E. Across theforehead
8. The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client’s foot in a basin of warm water placed on the bed. What action should the nursetake?
a. Remove the basin of water from the client’s bedimmediately
b. Remind the UAP to dry between the client’s toescompletely
c. Advise the UAP that this procedure is damaging to theskin
d. Add skin cream to the basin of water while the foot issoaking
9. The nurse in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected position in the community. The client is not a part of the colleague’s assignment. Which action should the nurseimplement?
a. Communicate the colleague’s actions to the unit chargenurse
b. Send an email to facility administration reporting theaction
c. Write an anonymous complaint to a professionalwebsite
d. Post a comment about the action on a staff discussionboard
10. At 0100 on a male client’s second postoperative night, the client states he is unstable to sleep and plans to read until feeling sleepy. What action should the nurseimplement?
a. Leave the room and close the door to the client’sroom
b. Assess the appearance of the client’s surgicaldressing
c. Bring the client a prescribed PRNsedative-hypnotic
d. Discuss symptoms of sleep deprivation with theclient
11. The nursing staff in the cardiovascular intensive care unit are creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect clientprivacy?
a. Remove identifying information of the clients whoparticipated
b. Recall that authored content may be legallydiscoverable
c. Share material from credible, peer reviewed sourcesonly
d. Respect all copyright laws when adding websitecontent
12. A male client with unstable angina needs a cardiac catheterization, so the healthcare provider explains the risks and benefits of the procedure, and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nursetake?
a. Answer the client’s specific questions with a short understandableexplanation
b. Postpone the procedure until the client understands the risks andbenefits
c. Call the client’s next of kin and ask them to provide verbalconsent
d. Page the healthcare provider to return and provide additionalexplanation
13. The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client toperform?
a. Tilt the pelvis forwards andbackwards
b. bend the arm by flexing the ulnar to thehumerus
c. Turn the head to the right andleft
d. Extend the arm at the ide and rotate incircles
14. A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse takefirst?
a. Access for side effects of themedication.
b. Document the client’sresponses.
c. complete a medication errorreport.
d. Determine if the pain wasrelieved.
15. When assessing a male client, the nurse finds that he is fatigue, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias.Basedonthesefindings,thenurseplanstochecktheclient’slaboratoryvaluestovalidatetheexistenceofwhich?
a. Hyperphosphatemia
b. Hypocalcemia
c. Hypermagnesemia
d. Hypokalemia
16. A female client’s significant other has been at her bedside providing reassurances and support for the past 3days, as desired by the client. The client’s estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurseimplement?
a. Obtain a perception from the healthcare provider regarding visitationprivileges
b. Request a consultation with the ethics committee for resolution of thesituation
c. Encouragetheclienttospeakwithherhusbandregardinghisdisruptivebehavior
d. Communicate the client’s wishes to all members of the multidisciplinaryteam
17. When measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. What follow-up action should the nurse takefirst?
a. Determine pulsepressure
b. Auscultate heartsounds
c. Measure oxygensaturation
d. Check for neck veindistention
18. To avoid nerve injury, what location should the nurse select to administer a 3 mL IMinjection?
a. Ventrogluteal
b. outer upper quadrant of thebuttock
c. Two inches below the acromion process
d. Vastuslateralis
19. Which instruction should the nurse include in the discharge teaching plan for an adult client withhypernatremia?
a. Monitor daily urine outputvolume
b. Drink plenty of water wheneverthirsty
c. Use salt tablets for sodium content
d. Review food labels for sodiumcontent
20. While changing a client’s post operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive MRSA, which is the most important action for the nurse totake?
A. Force oralfluids
B. Request a nutritionconsult
C. Initiate contactprecautions
D. Limit visitors to immediate familyonly
21. Toprepareaclientforthepotentialsideeffectsofanewlyprescribedmedication,whatactionshouldthenurseimplement?
a. Assesstheclientforhealthalterationsthatmaybeimpactedbytheeffectsofthemedication
b. Teach the client how to administer the medication to promote the bestabsorption
c. Administer a half dose and observe the client for side effects before administering a fulldosage
d. Encourage the client to drink plenty of fluids to promote effective drugdistribution
22. A client is 2 days post-op from a thoracic surgery and is complaining of incisional pain. The client last received pain medication 2 hours ago. He is rating his pain a 5 on a 1-10 scale. After calling the provider, what is the nurse’s nextaction?
a. instruct the client to use guided imagery and slow rhythmicbreathing
b. Provide at least 20 minutes of back massage and gentleeffleurage
c. Encourage the client to watchTV.
d. Place a hot water circulation device, such as an Aqua K pad, to operativesite
23. A client with cirrhosis and ascites is receiving furosemide 40 mg BID. The pharmacy provides 20 mg tablets. How many tablets should the client receive each day? [Enter numeric valueonly]
4 tablets
24. An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implementfirst?
a. Establish a toileting schedule to decrease episodes ofincontinence
b. Complete a functional assessment of the client’s self-careabilities
c. Apply a barrier ointment to intact areas that may be exposed tomoisture
d. Determine the size and depth of skin breakdown over the sacralarea
25. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during aninterview?
a. The client’s comfort level is increased when the nurse breaks eye contact to type notes into therecord
b. The interview process is enhanced with electronic documentation and allows the client to speak at a normalpace
c. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
d. Completing the electronic record during an interview is a legal obligation of the examiningnurse
26. A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencinganacuteepisodeofpainthatisnotrelievedbythismedicationregime.Theclienttellsthenursethatshedoesnotwanttohave
back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide?
a. Surgeryremovesthediskandistheonlytreatmentthatcantotallyresolvethepain
b. Themedicationregimenyoupreviouslyusedshouldbere-evaluatedfordoseadjustment
c. Massage and hot pack treatments are less invasive and can provide temporaryrelief
d. Acupuncture is a complementary therapy that is often effective for management ofpain
27. The nurse is providing wound care to a client with stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states “clean the wound and then apply collagenase.” collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the nurse cleanse the pressureulcer?
a. Lightly coat the wound with povidone-iodinesolution
b. Irrigate the wound with sterile normalsaline
c. Flush the wound with sterile hydrogenperoxide
d. Remove the eschar with a wet-to-drydressing
28. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurseimplement?
a. Document the client’s circadianrhythms
b. Assess for flushed, warm skin regularly
c. Measure temperature at regularintervals
d. Vary sites for temperaturemeasurement
29. When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implementfirst?
a. Position the client supine for a few minutes
b. Assist the client to stand at thebedside
c. Apply the blood pressure cuffsecurely
d. Record the client’s pulse rate andrhythm
30. The nurse retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN severe pain. How many mL should the nurse administer to the client? (Enter the numerical value only. If rounding is required , round to the nearest tenth) Ans:0.8
31. The unlicensed assistive personnel (UAP) describes the appearance of the bowel movement of several clients. Which description warrants additional follow up by the nurse? (select all thatapplies).
a. Solid with red streaks. b. Brown liquid.
c. Multiple hard pellets.
d. Formed but soft. e. Tarry appearance.
32. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment…she has not yet been fitted for a particulate filter mask.Which action should the nursetake?
a. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personalcare
b. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to thisclient
c. Instruct the UAP that a standard mask is sufficient for the provision of care for the assignedclient
d. Before changing assignments, determine which staff members have fitted particulate filtermasks
33. In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative nurse is arranging for discharge, the client verbalizes concerns about pain. What action should the nurseimplement?
a. Explain the respiratory problems that can occur with morphineuse.
b. Teach family how to evaluate the effectiveness ofanalgesics.
c. Recommend asking the healthcare professional for a patient-controlled analgesic (PCA)pump.
d. Provide client with a schedule of around-the-clock prescribed analgesicuse.
34. What assessment finding places a client at risk for problems associated with impaired skinintegrity?
a. Scattered macula of theface
b. Capillary refill 5seconds
c. Smooth nailtexture
d. Absence of skintenting
35. When evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse takenext?
a. Determine if the expected outcomes wererealistic
b. Obtain current client data to compare with expectedoutcomes
c. Modify the nursing interventions to achieve the client’sgoals
d. Review related professional standards of care
36. The nurse attaches a pulse oximeter to a client’s fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to thisreading?
a. BP 142/88 mmHg
b. 2+ edema of fingers andhands
c. Radial pulse volume is+3
d. Capillary refill time is 2seconds
37. The nurse is caring for a hospitalized client who was placed in restraints due to confusion. The family removes the restraints while they are with the client. When the family leaves, what action should the nurse takefirst?
a. Apply the restraints to maintain the client’ssafety.
b. Reassess the client to determine the need for continuingrestraints.
c. Document the time the family left and continue to monitor theclient.
d. Call the healthcare provider for a newprescription.
38. The nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse toimplement?
a. Instruct the client to repeat the medicationplan
b. Encourage client to take a PRN antianxietydrug
c. Provide written instructions that are easy tofollow
d. Include a family member in the teachingsession
39. What instruction should the nurse provide for an UAP caring for a client with MRSA who has a prescription for contactprecautions?
a. Do not allow visitors until precautions arediscontinued
b. Wear sterile gloves when handling the client’s bodyfluid
c. Have the client wear a mask whenever someone enters theroom
d. Don a gown and gloves when entering thereturn
40. While suctioning a client’s nasopharynx the nurse observes that the client’s oxygen saturation remains at 94% which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to thisfinding?
a. Complete the intermittent suction of thenasopharynx.
b. Reposition the pulse oximeter clip to obtain a newreading.
c. Stop suctioning until the pulse oximeter reading is above95%.
d. Apply an oxygen mask over the client’s nose andmouth
41. UAP has lowered the head of the bed to change the lines for a client who is bedless. Which observation…most immediate intervention by thenurse?
a. A feeding is infusing at 40 mL/hr through an enteral feedingtube
b. The urine meter attached to the urinary drainage bag is completelyfull
c. There is a large dependent loop in the client’s urinary drainagetubing
d. Purulent drainage is present around the insertion site of the feedingtube
42. A male client presents to the clinics stating that he has a high stress job and is having difficulty falling asleep at night. .The client reports having a constant headache and is seeking medication to help the sleep. Which intervention should the nurseimplement?
a. Determine the client’s sleep and activitypattern
b. Obtain prescription for client to take whenstressed
c. Refer client for a sleep study and neurologicalfollow-up
d. Teach coping strategies to use when feelingstressed
43. The nurse is teaching a client about use of the syringes and needles for home administration of medications. Which action by the client indicates an understanding of standardprecaution?
a. Remove needle before discarding usedsyringes
b. Wear gloves to dispose of the needle andsyringe
c. Done a face mask before administering themedication
d. Washes hands before handling the needle andsyringe
44. The nurse observes an UAP positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. Which action should the nurseimplement?
a. Instruct the UAP to obtain soft blankets to secure to the side rails instead ofpillows
b. Ensure that the UAP has placed pillows effectively to protect theclient
c. Ask the UAP to use some pillows to prop the client in a side-lyingposition
d. Assume responsibility for placing the pillows while the UAP complete anothertask
45. A cerebrovascular accident is placed on a ventilator. The client’s daughter arrives with a durable power of attorney, and a living will that indicates the…extraordinary life saving measures. What action should the nursetake?
a. Refer to the riskmanager
b. Notify the healthcareprovider
c. Discontinue theventilator
d. Review the medical record
46. Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the bestaction?
a. Ask the family to wait in the cafeteria when the next of kin makes the necessaryarrangements
b. Provide space and privacy for the family to share their concerns about the client’sdischarge
c. Ask the social worker to encourage the family to clear thehallway
d. Explain to the family the client’s need for privacy so that she can make independentdecisions
47. A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planningcare?
a. Amount of support provided by familymembers
b. Measurement of pain using a scale of 0 to10
c. The ability to perform ADLs
d. Nonverbal behaviors exhibited when painoccurs
48. A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that the chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse toimplement?
a. Evaluate the stool samples for presence ofblood
b. Assess for the presence of animpaction
c. Determine what home remedies wereused
d. Obtain list of prescribed homemedication
49. Which assessment data reflects the need for the nurses to include the problem, “Risk for falls” in a client’s plan ofcare?
a. Recent serum hemoglobin level of 16g/dL
b. Opioid analgesic received one hourago
c. Stooped posture with a steady gait
d. Expressed feelings ofdepression
50. The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL, for the previous 6 hour shift. Which intervention should the nurse implementfirst?
a. Check the drainage tubing for akink
b. Review the intake and outputrecord
c. Notify the healthcareprovider
d. Give the client 8 oz of water todrink
51. The nurse is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the nurse include in theassessment?
a. Provider an interpreter to convey the meaning of words and messages intranslation
b. Commend the client for her patience after a long wait in the admissionprocess
c. Arrange for the hospital chaplain to visit the client during her hospitalstay
d. Rely on cultural norms as the basis for providing nursing care for thisclient
52. During the admission assessment of a terminally ill male client that he is an agnostic. What is the best nursing action in response to this statement?
a. Provide information about the hours and location of thechapel
b. Document the statement of the client’s spiritualassessment
c. Invite the client to a healing service for people of allreligions
d. Offer to contact a spiritual advisor of the client’schoice
53. The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client states that the permit shouldinclude…
A. Notify the OR staff of the client’s confusion
B. Have the client sign a new surgical permit
C. Add the additional information to thepermit
D. Inform the surgeon about the client’s concern
54. The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out ofbed.
A. Administer nasal oxygen at a rate of 5L/min
B. Help the client to lie back down in thebed
C. Quickly pivot the client to the chair and elevate thelegs
D. Check the client’s blood pressure and pulsedeficit
55. When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nursetake
a. divert the client’sattention
b. Call for additional help from staff
c. Document the plannedaction
d. Re-assess the clientsituation
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