The nurse knows that a modifiable risk factor related to reducing the possibility of a second
myocardial infarction would be which factor?
{{Ans- . Change of diet to reduce fat intake
The nurse cares for the client who returned from a traditional cholecystectomy 45 minutes
ago. Since that time, the client's NG tube has been draining 75-100 mL per hour and the fluid
appears to be slightly blood tinged. The nurse must take which action first?
{{Ans- . Report the condition to the RN immediately
The nurse begins to prepare the deceased body for viewing by the family due to arrive in 20
minutes. The nurse is paged to assist a client to eat breakfast and to help another with morning
care and transfer to the chair. Which action by the nurse is most appropriate?
{{Ans- . Delegate the clients requiring help with breakfast and morning care to the nursing
assistive personnel and continue to prepare the body
The nurse observes the client falling out of a chair; which action should the nurse take first?
{{Ans- . Stay with the client and ask the AP to get the RN
The nurse should offer the client which food for a clear liquid diet?
{{Ans- . ½ cup of strawberry gelatin
The nurse observes an AP place a hot water bottle directly on the skin of an elderly patient.
Which of the following action should the nurse take first?
{{Ans- . Immediately remove the hot water bottle
The client insist that the nurse remove her vest restraint "immediately". What action by the
nurse is best?
{{Ans- . Check the health care provider's order to determine the criteria for removing the
restraint.
. The nurse knows that the treatment for pleurisy is which implementation?
{{Ans- . An anti-inflammatory medication
The nurse works with the client taking phenytoin for seizure prevention. Which instruction is
,the most essential for the nurse to reinforce regarding this medication?
{{Ans- . Notify the health care provider immediately if a skin rash develops
The RN mentions that the client diagnosed with borderline personality disorder uses the
defense mechanism of splitting. The nurse recognizes which presentation exemplifies splitting?
{{Ans- . Views other as either all good or all bad
The elderly client is admitted with severe substernal chest pain, tachypnea and tachycardia.
The client's skin is cool and clammy. The client becomes listless and has decrease in level of
consciousness. The nurse correctly identifies the cause of the client's symptoms as which
process? {{Ans- . Cardiogenic shock
The nurse cares for the client diagnosed with a tension pneumothorax. The client asks the
nurse, "which is the most serious complication?". Which is the best response by the nurse?
{{Ans- . Mediastinal shift
The nurse identifies which position is the best for the client immediately post liver biopsy?
{{Ans- . Right side-lying
Following a tornado, the nurse assists a disaster team by gathering data for victims who are
not physically injured. Which interview question is the best?
{{Ans- . Please share with me what help you need at this time.
. The client diagnosed with asthma currently takes beclomethasone dipropionate. The nurse is
aware that the most serious side effect of this medication are which findings?
{{Ans- . Bronchospasm and angioedema
The nurse cares for an elderly client diagnosed with type 2 DM and partial-thickness burns of
unknown origin on the lower legs and feet. Which reason if stated by the nurse is most likely
cause of the burns?
{{Ans- . Diabetes not being managed appropriately
. The client reports a sad mood, loss of pleasure in usually pleasurable things, and an inability
to sleep through the night. No manic episodes or psychotic behavior is noted in the outpatient
clinic. The nurse correctly understands that which diagnosis matches this client's presentation?
{{Ans- . Major depression
For three weeks, the client with a spinal cord injury at C7 and has had intensive sessions with
PT TID. the nurse determines the client is making expected progress if which finding is observed?
{{Ans- . The client is able to independently complete ADL
The HCP orders alprazolam 0.5 mg tablet PO TID. the available tablet contains 0.25 mg. How
,many tablets should the nurse give?
{{Ans- 6 tabs
The client states "I just haven't felt the best lately, I don't know what it is, I am not feeling like
my usual self." Based on the client's hx of two previous MI and HF, which question should the
nurse ask?
{{Ans- . Have you had any swelling in your feet or lower legs?
The middle aged adult reports fatigue, insomnia, and difficulty focusing on tasks. The client
has three teenagers in the home and is the primary caregiver for the client's elderly mother with
significant health problems. The nurse knows that one of the difficulties in this situation is what?
{{Ans- . Being a member of sandwich generation
The 3 month old infant was brought to the emergency room with a dx of SIDS. which question
is the most appropriate for the nurse to ask?
{{Ans- . What did the baby look like when you found him/her
The nurse suctions the client's trache, what is the most important action?
{{Ans- . Apply suction no longer than 10 seconds
The nurse instructs the AP to complete a bath for the client. The AP claims that they do not
have enough time. What action should the nurse take?
{{Ans- . Report to supervisor
Which instruction is essential for the nurse to give the client who has venous
thromboembolism of the left leg?
{{Ans- . Bed rest must be maintained until the anticoagulant therapy is begun
163. Client has COPD and pulmonary edema. Action
{{Ans- . Raise the head of the bed
A nurse Is collecting data from a client who received oxytocin 10 units IM 30 min ago
for excessive vaginal bleeding. Which of the following findings should the nurse expect?
{{Ans- - Client report of uterine cramping
A nurse is assisting with discharge planning for a group of clients. Which of the
following clients should the nurse recommend for a home care referral.
{{Ans- An older adult client who has heart failure and lives alone
A nurse is collecting data from the caregiver of a client who has Alzheimer's disease.
The caregiver reports that client has difficulty sleeping at night and wonder throughout
the house. Which of the following interventions for the nurse recommend.
, {{Ans- VEncourage Vthe Vclient Vto Vtake Vfrequent Vwalks Vduring Vthe Vday
A Vcharge Vnurse Von Va Vmental Vhealth Vunit Vis Vsupervising V a Vnewly Vlicensed Vnurse. VFor
whichVof Vthe VfollowingVactions Vby Vthe Vnewly Vlicensed Vnurse Vshould Vthe Vsupervising Vnurse
Vintervene?
{{Ans- VTells Va Vclient Vhe Vwill Vlose Vhis Vphone Vprivileges Vif Vhe Vdoes Vnot Vtake Vhis Vmedication
A Vnurse Vis Vreinforcing Vdietary Vteaching Vwith Va Vclient Vwho Vis Vat Vrisk Vfor
Vcardiovascular Vdisease. V WhichVof Vthe VfollowingVstatements V by Vthe Vclient Vindicates Van
Vunderstanding V of Vthe Vteaching? V{{Ans- V- V"I Vhave Vunsalted V pretzels Vfor Va Vsnack"
A Vnurse Vis Vreviewing Vthe Vhome Vmeds Vof Va Vclient Vwho Vrecently Vhad VTIAVto Vbegin Vtaking
Vclopidogrel. VThe Vnurse Vshould Vinstruct Vthe Vclient Vthat Vwhich Vof Vthe VfollowingVOTCVmeds
Vinteracts Vadversely Vw/ Vclopidogrel? V{{Ans- VNaproxen
A Vnurse V in V the Vproviders V officeVis Vcollecting Vdata Vfrom Va Vclient Vwho Vhas Vpsoriasis.
WhichVof Vthe Vfollowing Vstatements Vby Vthe Vclient Vshould Vthe Vnurse Vreport Vto Vthe Vprovider?
{{Ans- VI Vtry Vnot Vto VlookVat V the Vscales Von Vmy Vbody
A Vnurse Vis Vreceiving Vinfo Vabout Vadvance Vdirectives Vw/ Va Vnewly Vadmitted Vclient. VWhich
of Vthe VfollowingVstatements V by Vthe Vclient Vindicates Van Vunderstanding V of Vthe Vinformation?
{{Ans- V- VAdvance Vdirectives Vinclude Va V living Vwil
A Vnurse Vis Vreinforcing Vteaching VwithVthe Vsupport Vperson Vof Va Vclient Vwho Vis Vin Vthe
Vfirst Vstage Vof Vlabor. VWhichVof Vthe VfollowingVinstructions Vshould Vthe Vnurse Vinclude
Vregarding Veffleurage? V{{Ans- VGently Vstroke Vher Vabdomen Vduring Vcontractions
A Vnurse Vis Vcollecting Vdata Vfrom Va Vclient Vwho Vjust Vreceived Vhis Vfirst Vdose Vof
sulfasalazine Vto Vtreat Vulcerative Vcolitis. VWhich Vof Vthe VfollowingVfindings Vshould Vthe Vnurse
Videntify Vas Van Vindication Vof Van Vallergic V reaction Vto Vthis Vmedication. V{{Ans- V- VDyspnea
A Vnurse Vis Vcaring Vfor Va Vclient Vwho Vrecently Vgave Vbirth Vto Vher Vfirst Vchild. VThe
Vnewborn Vis Vcrying Vand Vthe Vclient Vstates, V"I Vcan'tVseem Vto Vdo Vanything Vright. VWhat
Vshould VI Vdo?. VWhich Vof Vthe Vfollowing Vresponses V should Vthe Vnurse Vmake?
{{Ans- VLet Vme Vshow VyouVhow Vto Vswaddle Vand Vcuddle Vhim, V then Vyou Vtry.
A Vcharge Vnurse Vin Va Vlong Vterm Vcare Vfacility Vis Vdeveloping Va Vperformance
Vimprovement Vplan VforVan VAP. VWhichVof Vthe VfollowingVactions Vshould Vthe Vnurse Vtake
Vwhen Vdeveloping Vthe Vplan? V(SATA
{{Ans- V- VSet Va Vspecic Vtime Vframe Vfor Vmeeting Vperformance Vgoals✅
- Ask Vthe Vnurse Vsupervisor Vto Vreview Vthe Vplan✅
- Include Vthe Vperformance Vstandard Vthat Vthe VAP Vshould Vmeet
myocardial infarction would be which factor?
{{Ans- . Change of diet to reduce fat intake
The nurse cares for the client who returned from a traditional cholecystectomy 45 minutes
ago. Since that time, the client's NG tube has been draining 75-100 mL per hour and the fluid
appears to be slightly blood tinged. The nurse must take which action first?
{{Ans- . Report the condition to the RN immediately
The nurse begins to prepare the deceased body for viewing by the family due to arrive in 20
minutes. The nurse is paged to assist a client to eat breakfast and to help another with morning
care and transfer to the chair. Which action by the nurse is most appropriate?
{{Ans- . Delegate the clients requiring help with breakfast and morning care to the nursing
assistive personnel and continue to prepare the body
The nurse observes the client falling out of a chair; which action should the nurse take first?
{{Ans- . Stay with the client and ask the AP to get the RN
The nurse should offer the client which food for a clear liquid diet?
{{Ans- . ½ cup of strawberry gelatin
The nurse observes an AP place a hot water bottle directly on the skin of an elderly patient.
Which of the following action should the nurse take first?
{{Ans- . Immediately remove the hot water bottle
The client insist that the nurse remove her vest restraint "immediately". What action by the
nurse is best?
{{Ans- . Check the health care provider's order to determine the criteria for removing the
restraint.
. The nurse knows that the treatment for pleurisy is which implementation?
{{Ans- . An anti-inflammatory medication
The nurse works with the client taking phenytoin for seizure prevention. Which instruction is
,the most essential for the nurse to reinforce regarding this medication?
{{Ans- . Notify the health care provider immediately if a skin rash develops
The RN mentions that the client diagnosed with borderline personality disorder uses the
defense mechanism of splitting. The nurse recognizes which presentation exemplifies splitting?
{{Ans- . Views other as either all good or all bad
The elderly client is admitted with severe substernal chest pain, tachypnea and tachycardia.
The client's skin is cool and clammy. The client becomes listless and has decrease in level of
consciousness. The nurse correctly identifies the cause of the client's symptoms as which
process? {{Ans- . Cardiogenic shock
The nurse cares for the client diagnosed with a tension pneumothorax. The client asks the
nurse, "which is the most serious complication?". Which is the best response by the nurse?
{{Ans- . Mediastinal shift
The nurse identifies which position is the best for the client immediately post liver biopsy?
{{Ans- . Right side-lying
Following a tornado, the nurse assists a disaster team by gathering data for victims who are
not physically injured. Which interview question is the best?
{{Ans- . Please share with me what help you need at this time.
. The client diagnosed with asthma currently takes beclomethasone dipropionate. The nurse is
aware that the most serious side effect of this medication are which findings?
{{Ans- . Bronchospasm and angioedema
The nurse cares for an elderly client diagnosed with type 2 DM and partial-thickness burns of
unknown origin on the lower legs and feet. Which reason if stated by the nurse is most likely
cause of the burns?
{{Ans- . Diabetes not being managed appropriately
. The client reports a sad mood, loss of pleasure in usually pleasurable things, and an inability
to sleep through the night. No manic episodes or psychotic behavior is noted in the outpatient
clinic. The nurse correctly understands that which diagnosis matches this client's presentation?
{{Ans- . Major depression
For three weeks, the client with a spinal cord injury at C7 and has had intensive sessions with
PT TID. the nurse determines the client is making expected progress if which finding is observed?
{{Ans- . The client is able to independently complete ADL
The HCP orders alprazolam 0.5 mg tablet PO TID. the available tablet contains 0.25 mg. How
,many tablets should the nurse give?
{{Ans- 6 tabs
The client states "I just haven't felt the best lately, I don't know what it is, I am not feeling like
my usual self." Based on the client's hx of two previous MI and HF, which question should the
nurse ask?
{{Ans- . Have you had any swelling in your feet or lower legs?
The middle aged adult reports fatigue, insomnia, and difficulty focusing on tasks. The client
has three teenagers in the home and is the primary caregiver for the client's elderly mother with
significant health problems. The nurse knows that one of the difficulties in this situation is what?
{{Ans- . Being a member of sandwich generation
The 3 month old infant was brought to the emergency room with a dx of SIDS. which question
is the most appropriate for the nurse to ask?
{{Ans- . What did the baby look like when you found him/her
The nurse suctions the client's trache, what is the most important action?
{{Ans- . Apply suction no longer than 10 seconds
The nurse instructs the AP to complete a bath for the client. The AP claims that they do not
have enough time. What action should the nurse take?
{{Ans- . Report to supervisor
Which instruction is essential for the nurse to give the client who has venous
thromboembolism of the left leg?
{{Ans- . Bed rest must be maintained until the anticoagulant therapy is begun
163. Client has COPD and pulmonary edema. Action
{{Ans- . Raise the head of the bed
A nurse Is collecting data from a client who received oxytocin 10 units IM 30 min ago
for excessive vaginal bleeding. Which of the following findings should the nurse expect?
{{Ans- - Client report of uterine cramping
A nurse is assisting with discharge planning for a group of clients. Which of the
following clients should the nurse recommend for a home care referral.
{{Ans- An older adult client who has heart failure and lives alone
A nurse is collecting data from the caregiver of a client who has Alzheimer's disease.
The caregiver reports that client has difficulty sleeping at night and wonder throughout
the house. Which of the following interventions for the nurse recommend.
, {{Ans- VEncourage Vthe Vclient Vto Vtake Vfrequent Vwalks Vduring Vthe Vday
A Vcharge Vnurse Von Va Vmental Vhealth Vunit Vis Vsupervising V a Vnewly Vlicensed Vnurse. VFor
whichVof Vthe VfollowingVactions Vby Vthe Vnewly Vlicensed Vnurse Vshould Vthe Vsupervising Vnurse
Vintervene?
{{Ans- VTells Va Vclient Vhe Vwill Vlose Vhis Vphone Vprivileges Vif Vhe Vdoes Vnot Vtake Vhis Vmedication
A Vnurse Vis Vreinforcing Vdietary Vteaching Vwith Va Vclient Vwho Vis Vat Vrisk Vfor
Vcardiovascular Vdisease. V WhichVof Vthe VfollowingVstatements V by Vthe Vclient Vindicates Van
Vunderstanding V of Vthe Vteaching? V{{Ans- V- V"I Vhave Vunsalted V pretzels Vfor Va Vsnack"
A Vnurse Vis Vreviewing Vthe Vhome Vmeds Vof Va Vclient Vwho Vrecently Vhad VTIAVto Vbegin Vtaking
Vclopidogrel. VThe Vnurse Vshould Vinstruct Vthe Vclient Vthat Vwhich Vof Vthe VfollowingVOTCVmeds
Vinteracts Vadversely Vw/ Vclopidogrel? V{{Ans- VNaproxen
A Vnurse V in V the Vproviders V officeVis Vcollecting Vdata Vfrom Va Vclient Vwho Vhas Vpsoriasis.
WhichVof Vthe Vfollowing Vstatements Vby Vthe Vclient Vshould Vthe Vnurse Vreport Vto Vthe Vprovider?
{{Ans- VI Vtry Vnot Vto VlookVat V the Vscales Von Vmy Vbody
A Vnurse Vis Vreceiving Vinfo Vabout Vadvance Vdirectives Vw/ Va Vnewly Vadmitted Vclient. VWhich
of Vthe VfollowingVstatements V by Vthe Vclient Vindicates Van Vunderstanding V of Vthe Vinformation?
{{Ans- V- VAdvance Vdirectives Vinclude Va V living Vwil
A Vnurse Vis Vreinforcing Vteaching VwithVthe Vsupport Vperson Vof Va Vclient Vwho Vis Vin Vthe
Vfirst Vstage Vof Vlabor. VWhichVof Vthe VfollowingVinstructions Vshould Vthe Vnurse Vinclude
Vregarding Veffleurage? V{{Ans- VGently Vstroke Vher Vabdomen Vduring Vcontractions
A Vnurse Vis Vcollecting Vdata Vfrom Va Vclient Vwho Vjust Vreceived Vhis Vfirst Vdose Vof
sulfasalazine Vto Vtreat Vulcerative Vcolitis. VWhich Vof Vthe VfollowingVfindings Vshould Vthe Vnurse
Videntify Vas Van Vindication Vof Van Vallergic V reaction Vto Vthis Vmedication. V{{Ans- V- VDyspnea
A Vnurse Vis Vcaring Vfor Va Vclient Vwho Vrecently Vgave Vbirth Vto Vher Vfirst Vchild. VThe
Vnewborn Vis Vcrying Vand Vthe Vclient Vstates, V"I Vcan'tVseem Vto Vdo Vanything Vright. VWhat
Vshould VI Vdo?. VWhich Vof Vthe Vfollowing Vresponses V should Vthe Vnurse Vmake?
{{Ans- VLet Vme Vshow VyouVhow Vto Vswaddle Vand Vcuddle Vhim, V then Vyou Vtry.
A Vcharge Vnurse Vin Va Vlong Vterm Vcare Vfacility Vis Vdeveloping Va Vperformance
Vimprovement Vplan VforVan VAP. VWhichVof Vthe VfollowingVactions Vshould Vthe Vnurse Vtake
Vwhen Vdeveloping Vthe Vplan? V(SATA
{{Ans- V- VSet Va Vspecic Vtime Vframe Vfor Vmeeting Vperformance Vgoals✅
- Ask Vthe Vnurse Vsupervisor Vto Vreview Vthe Vplan✅
- Include Vthe Vperformance Vstandard Vthat Vthe VAP Vshould Vmeet
