The charge nurse has received a change-of-shift report on the following clients in labor. The charge
nurse should ask a staff member to first see the client in the
1. first stage of labor who has an oral temperature of 99.7° F (37.6° C)
2. first stage of labor whose contractions are occurring every 30 seconds
3. second stage of labor who has respirations of 26
4. second stage of labor whose contractions are lasting for 60 seconds - ANS-2. first stage of labor
whose contractions are occurring every 30 seconds
Contractions should be no longer than 90 secs and no closer than 2 mins (120 secs)
90 secs is the duration, 2 mins is the frequency.
Rationale:
1. Elevated temp is normal during labor
3. Increased resps are normal during labor "pant-pant-blow" "hee-hee-hoo" breathing pattern
4. Contractions shouldn't be longer than 90 secs, 60 secs is okay and normal
Second stage: 2-3 mins apart, 60-90 secs long, 10 cm dilated, strong pain
The nurse is observing a staff member caring for a client who has chickenpox.
Which of the following actions by the staff member would require the nurse to intervene?
1. placing the client in a private room with monitored negative air pressure
2. placing a box of disposable face shields outside the client's room
3. placing an alcohol-based hand rub in the client's room for hand hygiene
4. placing a surgical mask on the client during transport out of the client's room - ANS-2. placing a
box of disposable face shields outside the client's room
disposable face masks are not suitable for airborne precautions
Rationale:
,Varicella (chickenpox) is airborne precaution. Private, negative pressure room, universal precautions
(hand sanitizer in room) and placing surgical mask on client during transport are all correct
interventions for Varicilla.
The nurse is caring for a client who reports feeling faint and is experiencing the cardiac rhythm
shown in the electrocardiogram (ECG) strip below.
- BRADYCARDIA (it is more than 5 spaces apart, sinus rhythm)
Which of the following actions would be appropriate for the nurse to take? Select all that apply:
1. Administer the client's prescribed beta blocker.
2. Prepare for transcutaneous pacing.
3. Instruct the client to perform the Valsalva maneuver.
4. Begin chest compressions.
5. Assess the client for angina. - ANS-2. transcutaneous pacing
- external pacing that stimulates the ventricles to pump at a set rate
5. Assess the client for angina
- Angina (Chest pain) can be caused by both tachycardia (most common) and bradycardia (rare but
can happen). Assessment of angina is appropriate
Rationale:
1. Beta blocker would further decrease HR
3. Valsalva maneuver/Vagal stimulation would further decrease HR. (can be indicated for sinus
Tachy)
4. Chest compressions are for cardiac arrest
The nurse is planning care for a client with moderate Alzheimer's disease (AD).
Which of the following interventions should the nurse include in the client's plan of care?
1. Encourage the client to reminisce about happy memories.
2. Confront the client when inappropriate or agitated behaviors occur.
3. Administer to the client the cholinesterase inhibitor to reverse the course of AD.
4. Provide the client with information about activity choices in the morning so the client can make
plans for the day. - ANS-1. Encourage the client to reminisce about happy memories.
Its possible for AD patients to retain long-term memories
,Rationale:
2. Acknowledge feelings --> Redirect is protocol for Dementia. Don't confront; they can't learn
3. AD is irreversible
4. In moderate AD, dementia has already progressed to where pt needs help with ADLs and planning
daily activities. Asking them to plan can frustrate them and cause distress.
STRUCTURED pleasant activities that consider the persons likes and interests are the best.
The nurse is teaching a client how to ambulate using crutches. Which of the following information
should the nurse include?
1. "Use your hands and arms to support your body weight."
2. "Wear slippers when ambulating with the crutches in your home."
3. "Maintain the crutches 12 in (30 cm) in front of your feet while standing."
4. "Adjust the hand grips of the crutches so that your elbows are fully extended." - ANS-1. "Use your
hands and arms to support your body weight."
True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s: paresis and
paresthesias in wrists and hands
Rationales:
2. Fall risk!
3. Should be 6 in. in front and 6 in. lateral
4. Elbows should be bent at 30 degree angle
The nurse has taught a client with multiple sclerosis (MS).
Which of the following statements by the client would indicate a correct understanding of the
teaching?
1. "I will complete all of my household chores in the morning when I am well rested."
2. "I have learned how to massage my bladder to help empty my bladder completely."
3. "I will take a hot bath in the evening to help me relax if I have had a stressful day at work."
4. "I should expect the blurred vision to resolve after I have received medications for several weeks."
- ANS-4. "I should expect the blurred vision to resolve after I have received medications for several
weeks."
MS causes nerve damage and can result in optic neuritis (vision loss, burry vision). In most cases it
resolves itself in 4-12 weeks, but medication (steroids) can speed up the process and resolve it
quicker
, Rationale:
1. MS patients should not exert themselves too much at one time. Space out activities and allow time
for rest.
2. Urinary retention is primarily treated by medication (bethanochol), and exercises can aid with it
but are not the primary treatment
3. Hot temperatures are bad for MS and can worsen symptoms. Your nerves are already fcked up and
extra heat can stress your body into overdrive
The nurse has attended a staff education program about caring for clients who are receiving positive
pressure mechanical ventilation. Which of the following statements by the nurse would indicate a
correct understanding of the teaching?
1. "Clients should avoid range-of-motion (ROM) exercises until weaned from ventilation."
2. "Clients may develop stress ulcers and gastrointestinal bleeding."
3. "Clients will be chemically paralyzed to improve oxygenation."
4. "Clients will experience diuresis and polyuria." - ANS-2. "Clients may develop stress ulcers and
gastrointestinal bleeding."
Rationale: Postive Pressure Ventilation may cause stress ulcers and GI bleeding because
The charge nurse must transfer a female client from the medical-surgical unit to the maternity unit
to make a bed available. It would be most appropriate for the nurse to transfer the client who is
1. 28 years old, had a right mastectomy and has a closed-wound drainage system
2. 49 years old, has diabetes mellitus (type 2) and has begun receiving insulin
3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
4. 70 years old, has a fractured left tibia and had an external fixation device applied 48 hours ago -
ANS-3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
The nurse has been made aware of the following client situations. The nurse should first assess the
client with:
1. heart failure who has a productive cough and is anxious
2. regional enteritis (Crohn's disease) who is reporting cramping abdominal pain and diarrhea
3. idiopathic thrombocytopenic purpura (ITP) who has petechiae on the trunk and is reporting heavy
menses
4. chronic obstructive pulmonary disease (COPD) who has dyspnea with exertion and is using
accessory muscles to breathe - ANS-1. heart failure who has a productive cough and is anxious
nurse should ask a staff member to first see the client in the
1. first stage of labor who has an oral temperature of 99.7° F (37.6° C)
2. first stage of labor whose contractions are occurring every 30 seconds
3. second stage of labor who has respirations of 26
4. second stage of labor whose contractions are lasting for 60 seconds - ANS-2. first stage of labor
whose contractions are occurring every 30 seconds
Contractions should be no longer than 90 secs and no closer than 2 mins (120 secs)
90 secs is the duration, 2 mins is the frequency.
Rationale:
1. Elevated temp is normal during labor
3. Increased resps are normal during labor "pant-pant-blow" "hee-hee-hoo" breathing pattern
4. Contractions shouldn't be longer than 90 secs, 60 secs is okay and normal
Second stage: 2-3 mins apart, 60-90 secs long, 10 cm dilated, strong pain
The nurse is observing a staff member caring for a client who has chickenpox.
Which of the following actions by the staff member would require the nurse to intervene?
1. placing the client in a private room with monitored negative air pressure
2. placing a box of disposable face shields outside the client's room
3. placing an alcohol-based hand rub in the client's room for hand hygiene
4. placing a surgical mask on the client during transport out of the client's room - ANS-2. placing a
box of disposable face shields outside the client's room
disposable face masks are not suitable for airborne precautions
Rationale:
,Varicella (chickenpox) is airborne precaution. Private, negative pressure room, universal precautions
(hand sanitizer in room) and placing surgical mask on client during transport are all correct
interventions for Varicilla.
The nurse is caring for a client who reports feeling faint and is experiencing the cardiac rhythm
shown in the electrocardiogram (ECG) strip below.
- BRADYCARDIA (it is more than 5 spaces apart, sinus rhythm)
Which of the following actions would be appropriate for the nurse to take? Select all that apply:
1. Administer the client's prescribed beta blocker.
2. Prepare for transcutaneous pacing.
3. Instruct the client to perform the Valsalva maneuver.
4. Begin chest compressions.
5. Assess the client for angina. - ANS-2. transcutaneous pacing
- external pacing that stimulates the ventricles to pump at a set rate
5. Assess the client for angina
- Angina (Chest pain) can be caused by both tachycardia (most common) and bradycardia (rare but
can happen). Assessment of angina is appropriate
Rationale:
1. Beta blocker would further decrease HR
3. Valsalva maneuver/Vagal stimulation would further decrease HR. (can be indicated for sinus
Tachy)
4. Chest compressions are for cardiac arrest
The nurse is planning care for a client with moderate Alzheimer's disease (AD).
Which of the following interventions should the nurse include in the client's plan of care?
1. Encourage the client to reminisce about happy memories.
2. Confront the client when inappropriate or agitated behaviors occur.
3. Administer to the client the cholinesterase inhibitor to reverse the course of AD.
4. Provide the client with information about activity choices in the morning so the client can make
plans for the day. - ANS-1. Encourage the client to reminisce about happy memories.
Its possible for AD patients to retain long-term memories
,Rationale:
2. Acknowledge feelings --> Redirect is protocol for Dementia. Don't confront; they can't learn
3. AD is irreversible
4. In moderate AD, dementia has already progressed to where pt needs help with ADLs and planning
daily activities. Asking them to plan can frustrate them and cause distress.
STRUCTURED pleasant activities that consider the persons likes and interests are the best.
The nurse is teaching a client how to ambulate using crutches. Which of the following information
should the nurse include?
1. "Use your hands and arms to support your body weight."
2. "Wear slippers when ambulating with the crutches in your home."
3. "Maintain the crutches 12 in (30 cm) in front of your feet while standing."
4. "Adjust the hand grips of the crutches so that your elbows are fully extended." - ANS-1. "Use your
hands and arms to support your body weight."
True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s: paresis and
paresthesias in wrists and hands
Rationales:
2. Fall risk!
3. Should be 6 in. in front and 6 in. lateral
4. Elbows should be bent at 30 degree angle
The nurse has taught a client with multiple sclerosis (MS).
Which of the following statements by the client would indicate a correct understanding of the
teaching?
1. "I will complete all of my household chores in the morning when I am well rested."
2. "I have learned how to massage my bladder to help empty my bladder completely."
3. "I will take a hot bath in the evening to help me relax if I have had a stressful day at work."
4. "I should expect the blurred vision to resolve after I have received medications for several weeks."
- ANS-4. "I should expect the blurred vision to resolve after I have received medications for several
weeks."
MS causes nerve damage and can result in optic neuritis (vision loss, burry vision). In most cases it
resolves itself in 4-12 weeks, but medication (steroids) can speed up the process and resolve it
quicker
, Rationale:
1. MS patients should not exert themselves too much at one time. Space out activities and allow time
for rest.
2. Urinary retention is primarily treated by medication (bethanochol), and exercises can aid with it
but are not the primary treatment
3. Hot temperatures are bad for MS and can worsen symptoms. Your nerves are already fcked up and
extra heat can stress your body into overdrive
The nurse has attended a staff education program about caring for clients who are receiving positive
pressure mechanical ventilation. Which of the following statements by the nurse would indicate a
correct understanding of the teaching?
1. "Clients should avoid range-of-motion (ROM) exercises until weaned from ventilation."
2. "Clients may develop stress ulcers and gastrointestinal bleeding."
3. "Clients will be chemically paralyzed to improve oxygenation."
4. "Clients will experience diuresis and polyuria." - ANS-2. "Clients may develop stress ulcers and
gastrointestinal bleeding."
Rationale: Postive Pressure Ventilation may cause stress ulcers and GI bleeding because
The charge nurse must transfer a female client from the medical-surgical unit to the maternity unit
to make a bed available. It would be most appropriate for the nurse to transfer the client who is
1. 28 years old, had a right mastectomy and has a closed-wound drainage system
2. 49 years old, has diabetes mellitus (type 2) and has begun receiving insulin
3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
4. 70 years old, has a fractured left tibia and had an external fixation device applied 48 hours ago -
ANS-3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
The nurse has been made aware of the following client situations. The nurse should first assess the
client with:
1. heart failure who has a productive cough and is anxious
2. regional enteritis (Crohn's disease) who is reporting cramping abdominal pain and diarrhea
3. idiopathic thrombocytopenic purpura (ITP) who has petechiae on the trunk and is reporting heavy
menses
4. chronic obstructive pulmonary disease (COPD) who has dyspnea with exertion and is using
accessory muscles to breathe - ANS-1. heart failure who has a productive cough and is anxious
