RECALLS 11 EXAM NP4

RECALLS 11 - NURSING PRACTICE IV 1) The nurse has instructed a client diagnosed with tuberculosis about how to prevent the spread of infection after discharge from the hospital. The nurse determines that the client needs further reinforcement of information if the client makes which statement? A. "I should use disposable plates, forks, and knives." B. "I should cough into tissues and throw them away carefully." C. "It's important to cover my mouth if I laugh, sneeze, or cough." D. "It's very important to wash my hands after I touch my mask, tissues, or body fluids." 2) A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis and is worried about the possibility of infecting family members and others. How should the nurse respond to provide reassurance? A. The family does not need therapy, and the client will not be contagious after 1 month of medication therapy. B. The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of medication therapy. C. The family will be treated prophylactically, and the client will not be contagious after 1 continuous week of medication therapy. D. The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy. 3) A client with active tuberculosis demonstrates less-than-expected interest in learning about the prescribed medication therapy. The nurse assesses that this client may ultimately need which intervention as a last resort? A. Directly observed therapy B. More medication instructions C. Involvement of the family in teaching D. Reinforcement by the primary health care provider 4) Which action by the parent of an infant with respiratory syncytial virus infection who is receiving ribavirin would indicate a need for further instruction regarding the management of the disease process? A. Wearing protective garb when visiting the infant B. Washing the hands before leaving the infant's room C. Telling a family member who has asthma that he should not visit the infant D. Telling the infant's aunt, who is pregnant, that it is acceptable to visit the infant 5) A client is seen in the health care clinic, and a diagnosis of acute sinusitis is made. The nurse provides home care instructions to the client regarding measures that will promote sinus drainage and comfort. Which statement by the client indicates a need for further instruction? A. "I should drink large amounts of fluids." B. "I should use a hot mist vaporizer to liquefy secretions." = HUMIDIFIER C. "I should try to sleep with the head of the bed elevated." D. "I should apply heat, such as a wet pack, over the sinuses." 6) A client has been receiving a series of medications as part of intravenous antineoplastic therapy. The nurse should implement neutropenic precautions after noting which laboratory result for this client? A. Ammonia level of 20 mcg/dL (33.3 mcmol/L) B. Platelet count of 100,000 mm3 (100 × 109/L) C. International normalized ratio (INR) of 1.2 seconds D. White blood cell (WBC) count of 2000 mm3 (2 × 109/L) 7) An assistive personnel (AP) is caring for a client who has an indwelling urinary catheter. Which action by the AP would indicate the need for further instruction in the care of the client? A. Used soap and water to cleanse the perineal area B. Allowed the drainage tubing to rest under the leg C. Kept the drainage bag below the level of the bladder D. Used the drainage tubing port to obtain urine samples 8) client who is admitted for an unrelated medical problem is diagnosed with urethritis caused by chlamydial infection. The assistive personnel (AP) assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. What should the nurse tell the AP? A. Enteric precautions should be instituted for the client. B. Gloves and mask should be used by caregivers in the client's room. C. Contact isolation should be initiated because the disease is highly contagious. D. Standard precautions are sufficient because the disease is transmitted sexually. 9) The nurse is conducting a community surveillance study for the purpose of communicable disease control. The nurse knows that performing an active surveillance method of assessment is best for what reason? A. Always results in clear indicators for interventions B. Results in detection of a more accurate number of cases C. Reflects an upward swing if a certain disease is current news D. Relies solely on the initiative of primary health care providers (PHCPs) to report cases 10) A registered nurse (RN) is providing instructions to an assistive personnel (AP) assigned to give a bed bath to a client who is on contact precautions. The RN instructs the AP to use which protective item when giving the bed bath? A. A gown and gloves B. Gloves and goggles C. A gown and goggles D. Gloves and shoe protectors 11) A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? A. Lying in bed on the affected side B. Lying in bed on the unaffected side C. Sims' position with the head of the bed flat D. Prone with the head turned to the side and supported by a pillow 12) The nurse is preparing to care for a client who has returned to the nursing unit after cardiac catheterization performed through the femoral vessel. The nurse checks the primary health care provider's (PHCP's) prescription and plans to allow which client position or activity after the procedure? A. Bed rest in high-Fowler's position B. Bed rest with bathroom privileges only C. Bed rest with head elevation at 60 degrees D. Bed rest with head elevation no greater than 30 degrees = 4- 6 HRS 13) A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? A. Monitoring the temperature B. Monitoring complaints of heartburn C. Giving warm gargles for a sore throat D. Assessing for the return of the gag reflex 14) The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement? A. "I know I must sign the consent form." B. "I hope the throat spray keeps me from gagging." C. "I'm glad I don't have to lie still for this procedure." D. "I'm glad some intravenous medication will be given to relax me." 15) A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure? A. Side-lying with a pillow under the hip B. Prone with a pillow under the abdomen C. Prone in slight Trendelenburg's position D. Side-lying with the legs pulled up and the head bent down onto the chest 16) A young adult client has never had a chest x-ray before and expresses to the nurse a fear of experiencing some form of harm from the test. Which statement by the nurse provides valid reassurance to the client? A. "You'll wear a lead shield to partially protect your organs from harm." B. "The amount of x-ray exposure is not sufficient to cause DNA damage." C. "The test isn't harmful at all. The most frustrating part is the long wait in radiology." D. "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation." 17) The nurse is explaining to an older client about a creatinine clearance test that has been prescribed. What response by the client indicates that there is a need for further teaching? A. "This test measures the levels of all of the medications that I take." = GFR B. "With aging, the kidneys don't clear all of my medications, so I can get very ill." C. "In older clients, changes in the renal system lead to less blood flow to the kidneys." D. "The primary health care provider has to do studies on my kidneys to see how they are filtering." 18) A client is scheduled for a Papanicolaou (Pap) smear at the next scheduled clinic visit. The nurse provides instructions to the client regarding preparation for this test. Which statement should the nurse include in the teaching? A. The test is painless. B. Fluids are restricted on the day of the test. C. The test can be performed during menstruation. D. Vaginal douching is required 2 hours before the test. 19) The nurse is caring for a client after pulmonary angiography with catheter insertion via the left groin. Which assessment finding is related to an allergic reaction to the contrast medium? A. Hypothermia B. Decreased blood pressure C. Hematoma in the left groin D. Discomfort in the left groin 20) The nurse provides information to a client scheduled for a dual x-ray absorptiometry (DEXA) test. Which information should the nurse provide to the client? Select all that apply. A. It is a painless test. B. It emits slightly more radiation than a chest x-ray does. C. Upper body clothing will need to be removed for testing. D. Increased fluid intake is necessary following the procedure. E. Metallic objects such as jewelry or belt buckles may interfere with the test and need to be removed. A. C,D B. B,D C. A,E D. NONE OF THE ABOVE 21) A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription? NORMAL : 10 – 13 SECON A. Adding a dose of heparin sodium B. Holding the next dose of warfarin C. Increasing the next dose of warfarin D. Administering the next dose of warfarin 22) A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? A. 3 mg/dL (1.08 mmol/L) B. 15 mg/dL (5.4 mmol/L) C. 29 mg/dL (10.44 mmol/L) D. 35 mg/dL (12.6 mmol/L 23) A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed? A. Discontinuing the heparin infusion B. Increasing the rate of the heparin infusion C. Decreasing the rate of the heparin infusion D. Leaving the rate of the heparin infusion as is 24) A client with a history of heart failure is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? A. 3.2 mEq/L (3.2 mmol/L) B. 3.8 mEq/L (3.8 mmol/L) C. 4.2 mEq/L (4.2 mmol/L) D. 4.8 mEq/L (4.8 mmol/L) 25) Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply. A. Platelets 35,000 mm3 (35 × 109/L) B. Sodium 150 mEq/L (150 mmol/L) C. Potassium 5.0 mEq/L (5.0 mmol/L) D. Segmented neutrophils 40% (0.40) E. Serum creatinine, 1 mg/dL (88.3 mcmol/L) F. White blood cells, 3000 mm3 (3.0 × 109/L) A. A, B, D F B. C, D, F C. A, D, E D. ALL OF THE ABOVE 26) A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? 7 % GOOD CONTROL 7-8% FAIR CONTROL >8% POOR CONTROL A. Avoiding infection B. Taking in adequate fluids C. Preventing and recognizing hypoglycemia D. Preventing and recognizing hyperglycemia 27) The nurse is caring for a client with a diagnosis of breast cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value? A. 2000 mm3 (2.0 × 109/L) B. 5800 mm3 (5.8 × 109/L) C. 8400 mm3 (8.4 × 109/L) D. 11,500 mm3 (11.5 × 109/L) 28) A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? A. Prepare to administer an antidote. B. Draw a sample for type and crossmatch and transfuse the client. C. Draw a sample for an activated partial thromboplastin time (aPTT) level. D. Draw a sample for prothrombin time (PT) and international normalized ratio (INR). 29) An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history? A. Dehydration B. Heart failure C. Iron deficiency anemia D. Chronic obstructive pulmonary disease 30) A client with a history of upper gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse should take which action after seeing the laboratory results? A. Report the abnormally low count. B. Report the abnormally high count. C. Place the client on bleeding precautions. D. Place the normal report in the client's medical record. 31) The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mmol/L), and HCO3– of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? FULLY COMPENSATED – NORMAL PH PARTIALLY COMPENSATED – ALL THREE ABNORMAL UNCOMPENSATED – EITHER PCO2/ HCO3 IS ABN A. Metabolic acidosis, compensated B Respiratory alkalosis, compensated C. Metabolic alkalosis, uncompensated D. Respiratory acidosis, uncompensated 32) The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis 33) A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypo ventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? A. A decreased pH and an increased Paco2 B. An increased pH and a decreased Paco2 C. A decreased pH and a decreased HCO3– D. An increased pH and an increased HCO3– = METABOLIC ALKALOSIS 34) The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm (72 mmol/L), and HCO3− = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? A. The client has acidotic blood. B. The client is probably overreacting. C. The client is fluid volume overloaded. D. The client is probably hyperventilating. 35) The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. A. Respirations that are shallow B. Respirations that are increased in rate C. Respirations that are abnormally slow D. Respirations that are abnormally deep E. Respirations that cease for several seconds A. A, E B. C, D C. B, D D. B, E 36) A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mmol/L), and HCO3- is 22 mEq/L (22 mmol/L) normal. The nurse interprets the results as indicating which condition? A. Metabolic acidosis with compensation B. Respiratory acidosis with compensation C. Metabolic acidosis without compensation D. Respiratory acidosis without compensation 37) The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. A. Nausea B. Confusion C. Bradypnea D. Tachycardia E. Hyperkalemia F. Lightheadedness A. A, B, D, F B. C, D, E, F C. A, B,C, D D. ALL OF THE ABOVE 38) The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? A. pH 7.25, Paco2 50 mm Hg B. pH 7.35, Paco2 40 mm Hg C. pH 7.50, Paco2 52 mm Hg D. pH 7.52, Paco2 28 mm Hg 39) The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? A. Sodium level of 145 mEq/L (145 mmol/L) B. Potassium level of 3.0 mEq/L (3.0 mmol/L) C. Magnesium level of 1.8 (0.74 mmol/L) D. Phosphorus level of 3.0 mg/dL (0.97 mmol/L) 40) The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? A. Respiratory acidosis from inadequate ventilation B. Respiratory alkalosis from anxiety and hyperventilation C. Metabolic acidosis from calcium loss due to broken bones D. Metabolic alkalosis from taking analgesics containing base products 41) The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? A. Weight loss and dry skin B. Flat neck and hand veins and decreased urinary output C. An increase in blood pressure and increased respirations D. Weakness and decreased central venous pressure (CVP) 42) The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented? A. Sustained tissue damage B. Requires nasogastric suction C. Has a history of Addison's disease D. Uric acid level of 9.4 mg/dL (557 mcmol/L) 43) The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. A. U waves B. Absent P waves C. Inverted T waves D. Depressed ST segment E. Widened QRS complex 44) The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? A. Twitching B. Hypoactive bowel sounds C. Negative Trousseau's sign D. Hypoactive deep tendon reflexes 45) The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL (2 mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Select all that apply. A. U waves B. Widened T wave C. Prominent U wave D. Prolonged QT interval E. Prolonged ST segment A. A, B, B. D, E C. B,C, D. ALL OF THE ABOVE 46) The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. A. ST depression B. Prominent U wave C. Tall peaked T waves D. Prolonged ST segment E. Widened QRS complexes A. A, B, B. D, E C. C, E D. ALL OF THE ABOVE 47) Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? A. The client who is taking diuretics B. The client with hyperaldosteronism C. The client with Cushing's syndrome D. The client who is taking corticosteroids 48) The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? A. Muscle twitches B. Decreased urinary output C. Hyperactive bowel sounds D. Increased specific gravity of the urine 49) The nurse reviews a client's laboratory report and notes that the client’s serum phosphorus (phosphate) level is 1.8 mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level? A. Malnutrition B. Renal insufficiency C. Hypoparathyroidism D. Tumor lysis syndrome 50) The nurse is reading a primary health care provider's (PHCP's) progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion? A. Urinary output B. Wound drainage C. Integumentary output D. The gastrointestinal tract 51) The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? A. A pregnant woman who exclaims, "My baby is not moving." B. A woman who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" C. A young child standing next to an adult family member who is screaming, "I want my mommy!" D. An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead." 52) The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? A. Prepare the triage rooms. B. Activate the emergency response plan. C. Obtain additional supplies from the central supply department. D. Obtain additional nursing staff to assist in treating the casualties. 53) The community health nurse is working with disaster relief after a tornado. The nurse assists in finding safe housing for survivors, providing support to families, organizing counseling, and securing physical care when needed. Which level of prevention does the nurse exercise? A. Primary level of prevention B. Secondary level of prevention C. Tertiary level of prevention D. Quaternary level of prevention 54) The nurse in the hospital emergency department is notified by emergency medical services that several victims who survived a plane crash will be transported to the hospital. Victims are suffering from cold exposure because the plane plummeted and was submerged in a local river. What is the initial action of the nurse? A. Call the nursing supervisor to activate the agency disaster plan. B. Supply the triage rooms with bottles of sterile water and normal saline. C. Call the intensive care unit to request that nurses be sent to the emergency department. D. Call the laundry department and ask the department to send as many warm blankets as possible to the emergency department. 55) The nurse is reviewing the manual of disaster preparedness and response for the annual hospital disaster drill. The nurse reads that which are functions of the American Red Cross (ARC) as opposed to the Federal Emergency Management Agency (FEMA) in the United States? Select all that apply. A. Provide monetary relief. B. Provide crisis counseling. C. Identify and train personnel. D. Issue presidential declarations. E. Deploy National Guard troops. F. Handle inquiries from families. A. A, B, D B. B, C, F C. C, E, F D. ALL OF THE ABOVE 56) The community health nurse is preparing to teach personnel and family preparedness for disasters to a group of parents of school-age children. Which items should the nurse plan to include in disaster preparedness? Select all that apply. A. Flashlight B. Supply of batteries C. Battery-operated radio D. Extra pair of eyeglasses E. 4-week supply of water F. 4-week supply of nonperishable food A. A, B, C, D B. B, C, E, F C. C, E, F D. NONE OF THE ABOVE 57) The nurse from a medical unit is called to assist with care for clients coming into the hospital emergency department during an external disaster. Using principles of triage during a disaster, the nurse should attend to the client with which problem first? A. Fractured tibia B. Penetrating abdominal injury C. Bright red bleeding from a neck wound D. Open massive head injury in deep coma 58) The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? A. A middle-aged man with 1 foot trapped under the wreckage B. A crying teenager who is holding pressure on an arm laceration C. A young woman who appears dazed and confused and is shivering D. A screaming middle-aged woman looking frantically for her husband 59) The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. A. Open doors to client rooms. B. Move beds away from windows. C. Close window shades and curtains. D. Place blankets over clients who are confined to bed. E. Relocate ambulatory clients from the hallways back into their rooms. A. B, C, D B. B, C, E, F C. C, E, F D. NONE OF THE ABOVE 60) The nurse is the first responder at the scene of a 6-car crash on a highway. Which victim should the nurse attend to first? A. A victim experiencing dyspnea B. A victim experiencing confusion C. A victim experiencing tachycardia D. A victim experiencing intense pain 61) A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? A. Each staff member is assigned a specific task for a group of clients. B. A staff member is assigned to determine the client's needs at home and begin discharge planning. C. A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an assistive personnel (AP). D. An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients. 62) The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? A. A client requiring a colostomy irrigation B. A client receiving continuous tube feedings C. A client who requires urine specimen collections D. A client with difficulty swallowing food and fluids 63) The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? A. A client who requires a bed bath B. An older client requiring frequent ambulation ZC. A client who requires hourly vital sign measurements D. A client requiring abdominal wound irrigations and dressing changes every 3 hours 64) The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. A. The acuity level of the clients B. Specific requests from the staff C. The clustering of the rooms on the unit D. The number of anticipated client discharges E. Client needs and workers' needs and abilities A. B, C B. A, E C. C, F D. ALL OF THE ABOVE 65) The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands? A. Every 2 hours B. Every 3 hours C. Every 4 hours D. Every 30 minutes 66) The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply. A. The nurse who never had roseola B. The nurse who never had mumps C. The nurse who never had chickenpox D. The nurse who never had German measles E. The nurse who never received the varicellazoster vaccine A. B, C B. A, D C. C, E D. ALL OF THE ABOVE 67) When creating an assignment for a team consisting of a registered nurse (RN), 1 licensed practical nurse (LPN), and 2 assistive personnel (AP), which is the best client for the LPN? A. A client requiring frequent temperature checks B. A client requiring assistance with ambulation every 4 hours C. A client on a mechanical ventilator requiring frequent assessment and suctioning D. A client with a spinal cord injury requiring urinary catheterization every 6 hours 68) When creating an assignment for a team consisting of 1 registered nurse (RN), 1 licensed practical nurse (LPN), and 2 assistive personnel (AP), which is the best client for the LPN? A. A client requiring frequent temperature checks B. A client requiring assistance with ambulation every 4 hours C. A client on a mechanical ventilator requiring frequent assessment and suctioning D. A client with a spinal cord injury requiring urinary catheterization every 6 hours 69) The registered nurse (RN) is planning assignments for the clients on a nursing unit. The RN needs to assign 4 clients and has 1 RN, 1 licensed practical nurse, and 2 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? A. The client who requires a 24-hour urine collection B. The client with an abdominal wound requiring frequent wound irrigations C. The older client requiring assistance with a bed bath and frequent ambulation D. The client on a mechanical ventilator requiring frequent assessment and suctioning 70) The nurse is caring for a client with acute glomerulonephritis. The nurse instructs the assistive personnel (AP) to implement which action when caring for the client? A. Ambulate the client frequently. B. Encourage a diet that is high in protein. C. Remove the water pitcher from the bedside. D. Monitor the client's temperature every 2 hours. 71) The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report? A. The client fell out of bed. B. The client climbed over the side rails. C. The client was found lying on the floor. D. The client became restless and tried to get out of bed. 72) A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? A. Obtain a court order for the surgical procedure. B. Ask the EMS team to sign the informed consent. C. Transport the victim to the operating room for surgery. D. Call the police to identify the client and locate the family. 73) The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action? A. Refuse to float to the ICU based on lack of unit orientation. B. Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. C. Ask the nursing supervisor to review the hospital policy on floating. D. Submit a written protest to nursing administration, and then call the hospital lawyer. 74) The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? A. Call security. B. Call the police. C. Call the nursing supervisor. D. Lock the coworker in the medication room until help is obtained. 75) A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? A. "I will sign as a witness to your signature." B. "You will need to find a witness on your own." C. "Whoever is available at the time will sign as a witness for you." D. "I will call the nursing supervisor to seek assistance regarding your request." 76) The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR? Select all that apply. A. Complete and file an occurrence report. B. Right-click on the entry and modify it to reflect the correct information. C. Document the correct information and end with the nurse's signature and title. D. Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. E. Document in a nurse's note in the client's record detailing the corrected information. A. B, C, D, E B. A, C, D C. C, D, E D. ALL OF THE ABOVE 77) Which identifies accurate nursing documentation notation(s)? Select all that apply. A. The client slept through the night. B. Abdominal wound dressing is dry and intact without drainage. C. The client seemed angry when awakened for vital sign measurement. D. The client appears to become anxious when it is time for respiratory treatments. E. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. A. B, C, D, E B. A, B, E C. C, D, E D. NONE OF THE ABOVE 78) A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? A. Performing a procedure without consent B. Threatening to give a client a medication C. Telling the client that he or she cannot leave the hospital D. Observing care provided to the client without the client's permission 79) Nursing staff members are sitting in the lounge taking their morning break. An assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the AP that making this accusation has violated which legal tort? A. Libel B. Slander C. Assault D. Negligence 80) An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? A. "Oh, really? I will discuss this situation with your son." B. "Let's talk about the ways you can manage your time to prevent this from happening." C. "Do you have any friends who can help you out until you resolve these important issues with your son?" D. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." 81) The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? A. A postoperative client preparing for discharge with a new medication B. A client requiring daily dressing changes of a recent surgical incision C. A client scheduled for a chest x-ray after insertion of a nasogastric tube D. A client with asthma who requested a breathing treatment during the previous shift 82) The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? A. A client complaining of muscle aches, a headache, and history of seizures B. A client who twisted her ankle when rollerblading and is requesting medication for pain C. A client with a minor laceration on the index finger sustained while cutting an eggplant D. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce. 83) The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? A. A client who is ambulatory demonstrating steady gait B. A postoperative client who has just received an opioid pain medication C. A client scheduled for physical therapy for the first crutch-walking session D. A client with a white blood cell count of 14,000 mm3 (14 x 109/L) and a temperature of 38. 4° C 84) The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? A. Finish the bed bath and then administer the pain medication to the other client. B. Ask the AP to find out when the last pain medication was given to the client. C. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete. D. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. 85) The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first-priority intervention in the event of this occurrence is which action? A. Immobilize the affected extremity. B. Remove jewelry and constricting clothing from the victim. C. Place the extremity in a position so that it is below the level of the heart. D. Move the victim to a safe area away from the snake and encourage the victim to rest. 86) The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs? A. Actual or life-threatening concerns B. Completing care in a reasonable time frame C. Time constraints related to the client's needs D. Obtaining needed supplies to care for the client 87) The nurse is assigned to care for 4 clients. In planning client rounds, which client should the nurse assess first? A. A postoperative client preparing for discharge with a new medication B. A client requiring daily dressing changes of a recent surgical incision C. A client scheduled for a chest x-ray after insertion of a nasogastric tube D. A client with asthma who requested a breathing treatment during the previous shift 88) The clinic nurse is caring for a client complaining of a foreign agent splashed into the eye. What intervention should the nurse employ before treatment? A. Put on gloves. B. Evaluate the client's visual acuity. C. Place the client in a supine position. D. Place a strip of pH paper in the lower sac of the client's affected eye. 89) A child with an autism spectrum disorder (ASD) is being admitted to the hospital for diagnostic tests. Which room assignment is the most appropriate for the child? A. Private room B. Semiprivate room C. 4-bed ward room D. Contact isolation room 90) The labor and delivery room nurse has just received reports on 4 clients. After reviewing the client data, the nurse should assess which client first? A. A primigravida client in the active stage of labor B. A multigravida client who was admitted for induction of labor C. A client who is not contracting but has suspected premature rupture of the membranes D. A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor 91) The nurse manager has involved all staff members in the development of goals and decision making. Which leadership style has the unit manager exercised? A. Autocratic B. Democratic C. Situational D. Laissez-faire 92) The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. A. Open doors to client rooms. B. Move beds away from windows. C. Close window shades and curtains. D. Place blankets over clients who are confined to bed. E. Relocate ambulatory clients from the hallways back into their rooms. A. B, C, D, B. A, B, E C. C, D, E D. NONE OF THE ABOVE 93) The nurse is seeking a leadership style that will empower staff to achieve excellence. Which leadership style should the nurse select to achieve this goal? A. Autocratic B. Situational C. Democratic D. Laissez-faire 94) The nurse educator presents an in-service training session on case management to nurses on the clinical unit. During the presentation the nurse educator clarifies that what is a characteristic of case management? A. Requires that 1 nurse take care of 1 client B. Promotes appropriate use of hospital personnel C. Requires a case manager who plans the care for all clients D. Uses a team approach, but 1 nurse supervises all other employees 95) The staff members working at the trauma center have characterized their nurse manager as task oriented and directive. Which leadership style does the nurse manager exhibit? A. Autocratic B. Situational C. Democratic D. Laissez-faire 96) The home health nurse develops a plan of care for the client. Which actions should the nurse include in the plan as a case manager of the client's care? A. Organize, manage, and balance health care services needed for the client. B. Report daily to all members of the client's health care team to advise them of the plans. C. Plan weekly meetings with all persons involved in the care of this client to assess status. D. Conduct daily teaching sessions for the client and significant others about the case management process. 97) The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for the assistive personnel (AP)? A. A client scheduled to receive parenteral nutrition B. A client who requires assistance with ambulation every 4 hours C. A client scheduled for discharge who needs teaching about medications D. A client with bladder cancer who is scheduled for a cardiac catheterization 98) The nurse is planning the client assignments for a group of clients and has a licensed practical nurse (LPN) and an assistive personnel (AP) on the nursing team. Which client would the nurse most appropriately assign to the LPN? A. A client with stable heart failure who has earlystage Alzheimer's disease B. A client who is scheduled for an electrocardiogram and a chest x-ray examination C. A client who was treated for dehydration, is weak, and needs assistance with bathing D. A client with emphysema who is receiving oxygen at 2 L/min by nasal cannula and becomes dyspneic on exertion 99) The registered nurse (RN) is planning client assignments and cannot take a client assignment today. Two assistive personnel (AP) and a licensed practical nurse (LPN) also are assigned to the unit. Which client should the RN most appropriately assign to the LPN? A. A client requiring frequent ambulation B. A client scheduled for a cardiac catheterization C. A client requiring range-of-motion (ROM) exercises D. A client with a 24-hour urine collection who is on strict bed rest 100) The registered nurse (RN) has provided instructions to a licensed practical nurse (LPN) regarding administering enemas to a client scheduled for a barium enema. The RN has instructed the LPN to administer enemas until they are clear. The LPN tells the RN that 3 enemas were administered and that the returns are still not clear. What most appropriate instruction should be given to the LPN? A. Administer 1 more enema. B. Stop administering the enemas. C. Continue to administer enemas until the solution is clear. D. Wait for 1 hour and then continue administering the enemas.