Question 1

The nurse is performing a central line tubing change when the client suddenly begins gasping for air and writhing.  Order the interventions by priority.  All options must be used.

Accepted Answer

A)  Administer oxygen as needed
B)  Clamp the catheter tubing
C)  Notify the health care provider (HCP) 
D)  Place the client in Trendelenburg position on the left side
E)  Stay with the client and provide reassurance B,D,A,C,E

Question 2

Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube?  Select all that apply.

Accepted Answer

A)  Ensure the client is given an analgesic 30-60 minutes before tube removal
B)  Instruct the client to breathe in, hold it, and bear down while the tube is being removed
C)  Place the client in the Trendelenburg position
D)  Prepare a sterile airtight petroleum jelly gauze dressing
E)  Provide the health care provider with sterile suture removal equipment A,B,D,E

Question 3

A home health nurse is teaching the spouse of an elderly client who experienced a stroke ways of reducing risks for falls in the home.  Which suggestion by the spouse would be the most effective plan to prevent falls?

Accepted Answer

A)  Have a respite caregiver come once a week to stay with the client so the spouse can go shopping
B)  Purchase a walker for the client to use when ambulating around the home
C)  Remove all area rugs and install grab bars in the bathroom
D)  Take the client for an annual eye exam and new glasses C

Question 4

A client is able to partially bear weight and follow the nurse's instructions.  Which would be the most appropriate method for the nurse to use to safely transfer this client?

Accepted Answer

A)  1-person stand and pivot with gait belt and walker
B)  1-person standby assist with walker
C)  2-person motorized stand-assist lift
D)  2-person stand and pivot with gait belt and walker

Question 5

The nurse recognizes that which factors place a client at increased risk for falls?  Select all that apply.

Accepted Answer

A)  Age of 50
B)  Diagnosis of ovarian cancer
C)  Lying pulse 80/min, standing pulse 110/min
D)  Osteoarthritis of knees
E)  Takes carbidopa/levodopaF) Uses a cane to ambulate

Question 6

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?

Accepted Answer

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 7

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.

Accepted Answer

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 8

The nurse is assessing the abdomen of a client experiencing gastrointestinal distress.  Place the answer choices in the correct order of assessment.  All options must be used.

Accepted Answer

A)  Auscultation
B)  Inspection
C)  Palpation
D)  Percussion
E)  Placement of client in supine position

Question 9

A nurse is caring for a 3-month-old client with a new tracheostomy.  Which findings would indicate a need for suctioning?  Select all that apply.

Accepted Answer

A)  Audible gurgling
B)  Heart rate 105/min
C)  Increased irritability
D)  Oxygen saturation 88%
E)  Respiratory rate 30/min

Question 10

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?

Accepted Answer

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 11

While preparing to insert a peripheral IV line, the nurse notices scarring near the client's left axilla.  The client confirms a history of left breast cancer and modified radical mastectomy.  Which actions should the nurse take?  Select all that apply.

Accepted Answer

A)  Advance the entire stylet into the vein upon venipuncture
B)  Insert the IV line into the most distal site of the right arm
C)  Place an appropriate precaution sign above the bed
D)  Review the medical record for history of mastectomy
E)  Teach the client to keep the left arm in a dependent position

Question 12

The nurse is preparing to transfer a client from the bed to the chair for the first time.  The client has generalized weakness and is unable to follow instructions.  Which would be the most appropriate method for the nurse to use to transfer this client safely?

Accepted Answer

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Question 13

The primary health care provider prescribes a 24-hour urine collection for a client with suspected Cushing syndrome.  Which instructions should the nurse give the client regarding this test?  Select all that apply.

Accepted Answer

A)  "A continuous urinary catheter must be inserted for this test and the urine will collect in an attached bag."
B)  "Keep the urine collection container in the refrigerator or a cooled ice chest when it is not in use."
C)  "Only daytime urine should be collected in the container as cortisol levels are higher in the morning."
D)  "Record the time the urine collection is started and then empty the bladder into the toilet so that the start time coincides with an empty bladder."
E)  "You will be given a dark plastic jug containing a powder that absorbs into the urine that you will collect in the jug."

Question 14

The nurse cares for a child with bed bug bites.  Which parent statement indicates that further teaching is required?

Accepted Answer

A)  "I need to have the entire house treated by pest control to ensure the bed bugs are gone."
B)  "I should concentrate on alleviating scratching as it can cause further complications."
C)  "My other family members and pets are at risk of bed bug bites."
D)  "This must have happened because I did not wash the bed sheets this week."

Question 15

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

Accepted Answer

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 
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 16

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?

Accepted Answer

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

Question 17

The nurse plans to start an IV line to infuse 2 units of packed red blood cells for a stable 42-year-old client with a gastrointestinal bleed.  Which IV catheter size is best?

Accepted Answer

A)  14-gauge
B)  18-gauge
C)  20-gauge
D)  22-gauge

Question 18

The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client.  Which statements made by the parents demonstrate correct understanding?  Select all that apply.

Accepted Answer

A)  "I can mix the medication in a bowl of my child's favorite cereal."
B)  "I should give another dose if my child vomits after taking the medication."
C)  "I should measure liquid medications using an oral syringe."
D)  "I will encourage my child to help me as I prepare the medication."
E)  "I will place my child in time-out if the medication is refused."

Question 19

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?

Accepted Answer

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 20

The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesions.  Which of the following actions are appropriate to include in the plan of care?  Select all that apply.

Accepted Answer

A)  Don gown, gloves, and N95 respirator when entering the client's room
B)  Ensure that pregnant staff members are not assigned to care for this client
C)  Place single-use, disposable thermometer and stethoscope in the room
D)  Place the client in a private room with negative air pressure
E)  Request discontinuation of isolation precautions once all lesions are dry and crusted

Exam 4: Fundamentals

The nurse is performing a central line tubing change when the client suddenly begins gasping for air and writhing. Order the interventions by priority. All options must be used.

Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube? Select all that apply.

A home health nurse is teaching the spouse of an elderly client who experienced a stroke ways of reducing risks for falls in the home. Which suggestion by the spouse would be the most effective plan to prevent falls?

A client is able to partially bear weight and follow the nurse's instructions. Which would be the most appropriate method for the nurse to use to safely transfer this client?

The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply.

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?

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.

The nurse is assessing the abdomen of a client experiencing gastrointestinal distress. Place the answer choices in the correct order of assessment. All options must be used.

A nurse is caring for a 3-month-old client with a new tracheostomy. Which findings would indicate a need for suctioning? Select all that apply.

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?

While preparing to insert a peripheral IV line, the nurse notices scarring near the client's left axilla. The client confirms a history of left breast cancer and modified radical mastectomy. Which actions should the nurse take? Select all that apply.

The nurse is preparing to transfer a client from the bed to the chair for the first time. The client has generalized weakness and is unable to follow instructions. Which would be the most appropriate method for the nurse to use to transfer this client safely?

The primary health care provider prescribes a 24-hour urine collection for a client with suspected Cushing syndrome. Which instructions should the nurse give the client regarding this test? Select all that apply.

The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required?

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

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?

The nurse plans to start an IV line to infuse 2 units of packed red blood cells for a stable 42-year-old client with a gastrointestinal bleed. Which IV catheter size is best?

The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client. Which statements made by the parents demonstrate correct understanding? Select all that apply.

The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesions. Which of the following actions are appropriate to include in the plan of care? Select all that apply.