CBC PRACTICE EXAM 4 A FULLY SOLVED & VERIFIED 2024 LATEST UPDATE ALREADY GRADED A+(100% ACCURATE)

A nurse is assessing a client who has a do-not-resuscitate (DNR) order and has stopped breathing. The family asks the nurse to resuscitate the client. Which of the following actions should the nurse take? A) Begin CPR on the client. B) Respect the client's preferences. C) Apply oxygen at 4 L/min via nasal cannula. D) Gather equipment for mechanical ventilation. A) Begin CPR on the client. Rationale: The nurse should not begin CPR on the client, because this action goes against the client's DNR order. B) Respect the client's preferences. Rationale: The nurse should inform the client's family that he is obligated to respect the client's preferences and follow the DNR order. C) Apply oxygen at 4 L/min via nasal cannula. Rationale: The nurse should not apply oxygen at 4 L/min via nasal cannula, because this action goes against the client's DNR order. D) Gather equipment for mechanical ventilation. Rationale: The nurse should not gather equipment for mechanical ventilation, because this action goes against the client's DNR order. A nurse is caring for a client who has a new diagnosis of esophageal cancer. The client's family tells the nurse that they do not want the client to know the diagnosis. Which of the following actions should the nurse take to uphold client autonomy? A) Ask the provider to respect the family's decision to withhold the diagnosis. B) Tell the family the client has the right to know about her health. C) Agree to keep the diagnosis information from the client. D) Request pastoral care to inform the client of her condition. A) Ask the provider to respect the family's decision to withhold the diagnosis. Rationale: The nurse is demonstrating paternalism by asking the provider to respect the family's decision to withhold the diagnosis. B) Tell the family the client has the right to know about her health. Rationale: The nurse is demonstrating the ethical principle of autonomy by respecting the client's right to make decisions about her health. C) Agree to keep the diagnosis information from the client. Rationale: The nurse is demonstrating paternalism by agreeing to keep the diagnosis information from the client. D) Request pastoral care to inform the client of her condition. Rationale: The nurse is breaching confidentiality by requesting pastoral care to inform the client of her condition. A nurse is teaching a group of assistive personnel about prevention pressure ulcers. Which of the following images should the nurse include in the teaching? A) Side-lying B) Fowler's C) Semi Fowler's with heels raised D) Wheelchair with a cushion A) Side-lying Rationale: The nurse should teach the assistive personnel to avoid positioning the client in the lateral position directly on the trochanter, but should tilt the client back with pillow support and pillows between the legs at the knees. Lying directly on the trochanter or having the knees against each other can cause excess pressure from bony prominences on blood vessels at the point of contact and lead to a pressure ulcer. B) Fowler's Rationale: The nurse should teach the assistive personnel to avoid positioning the head of bed at greater than 30° for an extended period of time. Shearing can occur from the client sliding down in bed causing the client's skin to remain stationary while the underlying tissue shifts, decreasing blood supply to the skin tissue, which can lead to a pressure ulcer. C) Semi Fowler's with heels raised Rationale: The nurse should teach the assistive personnel to place a pillow or blankets under the client's legs or ankles to prevent the heel from rubbing on the bed linens and causing a friction rub that can lead to a pressure ulcer. The head of the bed should be positioned at less than 30° to prevent shearing pressure. D) Wheelchair with a cushion Rationale: The nurse should teach the assistive personnel to not place a donut-shaped pillow in a wheelchair or chair because the pillow can compress and damage capillaries and increase tissue breakdown, which can lead to pressure ulcers. A community health nurse is teaching a newly licensed nurse about the types of psychiatric health care settings available in the community. Which of the following should the nurse identify as a primary care setting? A) Partial hospitalization program B) Locked inpatient unit C) Day treatment program D) Outpatient counseling clinic A) Partial hospitalization program Rationale: Partial hospitalization programs provide clients with short, intensive mental health treatments similar to inpatient treatments. However, patients are allowed to return home each day. Typically, the program lasts 5 to 6 hr per day. B) Locked inpatient unit Rationale: The most acute treatment facility for clients seeking mental health care is a locked inpatient unit. C) Day treatment program Rationale: Day treatment programs provide clients with behavioral regulation and social skills development. However, patients are allowed to return home each day. D) Outpatient counseling clinic Rationale: Outpatient counseling clinics are primary care settings that provide strategies for clients to prevent or delay mental health issues. A nurse suspects that a client is experiencing a pulmonary embolism. Which of the following actions should the nurse take first? A) Check the client for sacral edema. B) Raise the head of the client's bed. C) Obtain the client's blood pressure in both arms. D) Prepare the client for a chest x-ray. A) Check the client for sacral edema. Rationale: The nurse should check the client for sacral edema to assess for fluid retention or bleeding in the body. However, there is another action the nurse should take first. B) Raise the head of the client's bed. Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to client care is to raise the head of the bed to allow for ease of breathing and better oxygenation. C) Obtain the client's blood pressure in both arms. Rationale: The nurse should obtain the client's blood pressure in both arms to assess his cardiac status and adequacy of perfusion. However, there is another action the nurse should take first. D) Prepare the client for a chest x-ray. Rationale: The nurse should prepare the client for a chest x-ray to diagnose the presence of a pulmonary embolism in his lung. However, there is another action the nurse should take first. A nurse is caring for clients on a medical-surgical unit. Which of the following actions by the nurse demonstrates the professional characteristic of human dignity? A) The nurse treats each of his assigned clients with equal respect. B) The nurse offers to help overwhelmed coworkers with client care. C) The nurse respects the right of a client who has chronic kidney disease to choose to stop dialysis. D) The nurse contacts an interpreter for a client who does not speak the same language as the nurse. A) The nurse treats each of his assigned clients with equal respect. Rationale: This action by the nurse is an example of the professional characteristic of human dignity, which includes treating all clients equally regardless of medical history or background. B) The nurse offers to help overwhelmed coworkers with client care. Rationale: This action by the nurse is an example of the professional characteristic of altruism. C) The nurse respects the right of a client who has chronic kidney disease to choose to stop dialysis. Rationale: This action by the nurse is an example of the professional characteristic of autonomy. D) The nurse contacts an interpreter for a client who does not speak the same language as the nurse. Rationale: This action is an example of the professional characteristic of social justice. A nurse is caring for a client who has an adrenal gland disorder. Which of the following actions should the nurse take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data. Exhibit 1: History and Physical​ Cushing's Disease: Striae on abdomen and thighs Bruising on lower extremities Open sore on ankle with cellulitis Acne on face and chest Exhibit 2: Diagnostic Results Potassium 4.6 mEq/L Sodium 149 mEq/L BUN 20 mg/dL Hemoglobin 12.8 g/dL Hematocrit 42 % Exhibit 3: Nurses' Notes Bounding peripheral pulses Distended neck veins Edema across the sacrum A) Administer an oral potassium supplement to the client. B) Apply a pressure-reducing overlay on the client's mattress. C) Check the client for orthostatic hypotension. D) Administer a 0.9% sodium chloride IV bolus to the client. A) Administer an oral potassium supplement to the client. Rationale: The nurse should not administer an oral potassium supplement to the client, because the client's potassium level is within the expected reference range. However, the nurse should monitor the client's potassium level for hypokalemia. B) Apply a pressure-reducing overlay on the client's mattress. Rationale: The nurse should apply a pressure-reducing overlay on the client's mattress because the edema across the client's sacrum can result in a pressure ulcer. The edema is caused by hypercortisolism that leads to fluid retention. C) Check the client for orthostatic hypotension. Rationale: The nurse should check the client for hypertension because the client is experiencing manifestations of fluid volume overload, including bounding peripheral pulses, distended neck veins, and edema across the sacrum. D) Administer a 0.9% sodium chloride IV bolus to the client. Rationale: The nurse should not administer a 0.9% sodium chloride IV bolus to the client because the client's sodium level is above the expected reference range, which can lead to fluid volume overload. A client who has adrenal gland hyperfunction or Cushing's disease can have hypernatremia and fluid retention. A charge nurse is facilitating conflict resolution between two coworkers regarding a client assignment. Which of the following conflict management strategies should the charge nurse use first? A) Focus on the issue to resolve and meet the needs of each coworker. B) Determine how each coworker manages personal conflicts. C) Ask both of the coworkers for information about the situation. D) Listen attentively to the concerns of each coworker. A) Focus on the issue to resolve and meet the needs of each coworker. Rationale: The nurse should focus on the issues in order to find a resolution to meet the needs of each coworker. However, evidence-based practice indicates that the nurse should perform another action first. B) Determine how each coworker manages personal conflicts. Rationale: Evidence-based practice indicates the charge nurse first needs to understand the conflict management style of each coworker. Respecting each other's feelings about the conflict and realizing that everyone handles conflicts differently are the first steps to successfully resolving the conflict. C) Ask both of the coworkers for information about the situation. Rationale: The nurse should ask both nurses about the situation to help resolve the conflict. However, evidence-based practice indicates that the nurse should perform another action first. D) Listen attentively to the concerns of each coworker. Rationale: The nurse should listen to the concerns of each coworker to understand both sides of the situation. However, evidence-based practice indicates that the nurse should perform another action first. A nurse caring for a client who has sepsis. Which of the following manifestations should indicate to the nurse that the client might be progressing to septic shock? A) Bradycardia B) Hypertension C) Hypothermia D) Polyuria A) Bradycardia Rationale: The nurse should recognize that a client who is progressing to septic shock can experience tachycardia as a result of the body's attempt to preserve organ function. B) Hypertension Rationale: The nurse should recognize that a client who is progressing to septic shock can experience hypotension as a result of the body's inability to compensate for the infection. C) Hypothermia Rationale: The nurse should recognize that a client who is progressing to septic shock can experience hypothermia as a result of the body's inability to compensate for the infection. D) Polyuria Rationale: The nurse should recognize that a client who is progressing to septic shock can experience decreased urine production as organ failure occurs. A nurse manager is teaching a unit nurse about case management. Which of the following information should the nurse manager include in the teaching about the role of the nurse as a case manager? A) Independently manages the care of the client B) Limited to inpatient care settings due to length of stay C) Advocates for services the client needs D) Provides direct client care to manage client outcomes A) Independently manages the care of the client Rationale: A nurse case manager collaboratively manages care of the client with the interprofessional health care team to plan, facilitate, and advocate for the best options and services available to the client for extended care following discharge. B) Limited to inpatient care settings due to length of stay Rationale: A nurse case manager's role can extend to outpatient settings and is not limited to the inpatient environment because of the shortened length of stay in acute care. C) Advocates for services the client needs Rationale: A nurse case manager's role is to advocate for services needed and available resources to meet the client's needs. D) Provides direct client care to manage client outcomes Rationale: A nurse case manager uses critical pathways and nursing care plans, rather than providing direct client care, to manage expected client outcomes in a specific timeframe. A nurse is teaching a client who had an organ transplant about cyclosporine therapy. Which of the following instructions should the nurse include in the teaching? A) "Avoid drinking grapefruit juice when taking this medication." B) "Plan to discontinue taking this medication after 6 months." C) "Schedule dental examinations once per year." D) "Expect your urine to turn orange in color when taking this medication." A) "Avoid drinking grapefruit juice when taking this medication." Rationale: The nurse should instruct the client to avoid drinking grapefruit juice while taking this medication. Grapefruit juice can decrease the metabolism of cyclosporine, which can cause an increase in serum levels and increase the risk for toxicity. B) "Plan to discontinue taking this medication after 6 months." Rationale: The nurse should instruct the client that cyclosporine is a lifelong therapy to prevent rejection of the transplanted organ. C) "Schedule dental examinations once per year." Rationale: The nurse should instruct the client to schedule dental examinations every 3 months to monitor for gingival hyperplasia. D) "Expect your urine to turn orange in color when taking this medication." Rationale: The nurse should instruct the client to report dark brown urine because this can indicate hepatotoxicity. A nurse is caring for a client who has sepsis and has developed disseminated intravascular coagulation (DIC). Which of the following actions should the nurse take? A) Obtain the client's rectal temperature every 2 hr. B) Perform mouth care for the client using glycerin swabs. C) Administer anticoagulants to the client. D) Monitor the client's breath sounds every 8 hr. A) Obtain the client's rectal temperature every 2 hr. Rationale: The nurse should avoid obtaining rectal temperatures due to the increased risk for rectal bleeding. B) Perform mouth care for the client using glycerin swabs. Rationale: The nurse should avoid using glycerin swabs due to their drying effects on the mucosa, which increases the risk for bleeding. C) Administer anticoagulants to the client. Rationale: The nurse should administer anticoagulants to limit the clotting. D) Monitor the client's breath sounds every 8 hr. Rationale: The nurse should monitor the client's breath sounds at least every 2 to 4 hr to assess for crackles and other manifestations of fluid overload. A nurse is providing discharge teaching to a client who has hepatitis. Which of the following information should the nurse include? A) "Take acetaminophen for minor aches and pains." B) "Eat low-carbohydrate, high-protein meals." C) "Avoid sexual intercourse until the antibody test is negative." D) "Wait at least 6 months before donating blood." A) "Take acetaminophen for minor aches and pains." Rationale: The nurse should inform the client to avoid all medications, including over-the-counter medications, such as acetaminophen, unless prescribed by the provider. B) "Eat low-carbohydrate, high-protein meals." Rationale: The nurse should inform the client to eat small, frequent meals containing high-carbohydrate, moderate-fat, and moderate-protein content. C) "Avoid sexual intercourse until the antibody test is negative." Rationale: The nurse should inform the client to avoid sexual intercourse until the antibody testing results are negative. D) "Wait at least 6 months before donating blood." Rationale: The nurse should inform the client who has hepatitis that donating blood, body organs, or other body tissue is no longer a viable option. A nurse is caring for a client who has chronic kidney disease and is taking hydrochlorothiazide. The nurse should monitor the client's laboratory values for which of the following findings? A) Hypokalemia B) Hyperphosphatemia C) Hypocalcemia D) Hypermagnesemia A) Hypokalemia Rationale: The nurse should monitor the client's laboratory values for a decrease in potassium while the client is taking a thiazide diuretic due to the client's increased excretion of water and electrolytes. B) Hyperphosphatemia Rationale: The nurse should monitor the client's laboratory values for a decrease in phosphorus while the client is taking a thiazide diuretic. C) Hypocalcemia Rationale: The nurse should monitor the client's laboratory values for an increase in calcium while the client is taking a thiazide diuretic. D) Hypermagnesemia Rationale: The nurse should monitor the client's laboratory values for a decrease in magnesium while the client is taking a thiazide diuretic. A nurse manager is discussing Medicare reimbursement with a group of staff nurses. The nurse should identify that Medicare will deny reimbursement for which of the following events? A) Allergic reaction to an immunization B) Additional round of antibiotics for the treatment of community-acquired pneumonia C) Fractured hip from a fall while ambulating postoperatively D) Adverse effect of constipation from morphine A) Allergic reaction to an immunization Rationale: Allergic reactions are a potential response to immunizations. Treatment of allergic reactions is reimbursed by Medicare. B) Additional round of antibiotics for the treatment of community-acquired pneumonia Rationale: Clients who have uncomplicated pneumonia can receive treatment for 5 to 7 days. However, clients who are immunocompromised can require treatment for up to 21 days. Treatment of community-acquired pneumonia is reimbursed by Medicare. C) Fractured hip from a fall while ambulating postoperatively Rationale: Medicare denies reimbursement for "never events." These events are considered preventable and include hospital-acquired infections, injuries resulting from a client fall, and surgery performed to an incorrect site. D) Adverse effect of constipation from morphine Rationale: Constipation is a common adverse effect of morphine. Treatment of adverse effects is reimbursed by Medicare. A nurse is caring for a group of postpartum clients. Which of the following tasks should the nurse delegate to an assistive personnel? A) Monitor the reflexes of a client who has preeclampsia. B) Measure the urine output of a client who is receiving magnesium sulfate. C) Check the pain level of a client who has received analgesia. D) Reinforce teaching about perineal care for a client who had an episiotomy. A) Monitor the reflexes of a client who has preeclampsia. Rationale: Monitoring reflexes is an assessment, which requires use of the nursing process. Therefore, this task is not within the range of function of an assistive personnel. B) Measure the urine output of a client who is receiving magnesium sulfate. Rationale: Measuring the urine output of a client who is receiving magnesium sulfate does not require use of the nursing process and is within the range of function of an assistive personnel. C) Check the pain level of a client who has received analgesia. Rationale: Checking the pain level of a client who has received analgesia is an assessment, which requires use of the nursing process. Therefore, this task is not within the range of function of an assistive personnel. D) Reinforce teaching about perineal care for a client who had an episiotomy. Rationale: Reinforcing teaching about perineal care for a client who had an episiotomy requires the use of clinical judgment and critical thinking. Therefore, this task is not within the range of function of an assistive personnel. A nurse is working on an interprofessional collaboration plan for care for a client who has stage III pressure ulcer. Which of the following actions should the nurse recognize as the role of the licensed practical nurse? A) Administer pain medication. B) Initiate the plan of care. C) Determine protein needs for the client. D) Prescribe a referral for physical therapy. A) Administer pain medication. Rationale: The nurse should identify that the administration of pain medicine is within the scope of practice of a licensed practical nurse. B) Initiate the plan of care. Rationale: The nurse should identify that a registered nurse should initiate the plan of care. C) Determine protein needs for the client. Rationale: Determine protein needs for the client. The nurse should identify that determining protein needs for the client is the role of the dietitian. D) Prescribe a referral for physical therapy. Rationale: The nurse should identify that prescribing a referral for physical therapy is the role of the provider. A nurse is caring for a client who has hepatic encephalopathy and is receiving lactulose. The nurse should identify that which of the following findings indicates a therapeutic effect of the medication? A) Decreased abdominal girth B) Decreased ammonia level C) Decreased heart rate D) Decreased abdominal cramping A) Decreased abdominal girth Rationale: The nurse should monitor the client for a decreased abdominal girth as an indication of the effectiveness of diuretic therapy. B) Decreased ammonia level Rationale: The nurse should identify that a decrease in the client's ammonia level is a therapeutic effect of lactulose. This medication decreases ammonia levels by producing a laxative effect. Another therapeutic effect of the medication is decreased confusion. C) Decreased heart rate Rationale: The nurse should identify that a decreased heart rate is a therapeutic effect of beta blockers. These medications can be given to reduce hepatic venous pressure and bleeding. D) Decreased abdominal cramping Rationale: The nurse should identify abdominal cramping as an adverse effect of lactulose. A nurse is providing preoperative teaching to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take? A) Contact a trained interpreter to translate the teaching for the client. B) Translate the teaching for the client using a bilingual dictionary. C) Ask the client's family member to translate the teaching for the client. D) Use a computer-generated translation service to translate the teaching for the client. A) Contact a trained interpreter to translate the teaching for the client. Rationale: The nurse's role is to contact a professional interpreter who is trained in medical terminology to promote the client's understanding of the teaching. B) Translate the teaching for the client using a bilingual dictionary. Rationale: The nurse should not translate the teaching, as this can result in translation errors and impede the client's understanding of the teaching. C) Ask the client's family member to translate the teaching for the client. Rationale: The nurse should not ask the client's family member to translate the teaching, as this can result in translation errors and violate the client's privacy. D) Use a computer-generated translation service to translate the teaching for the client. Rationale: The nurse should not translate the teaching, even using a computer-generated