NR 449 EVIDENCE BASED PRACTICE Questions and answers
1. A nurse is caring for a client who is wearing antiembolic stockings. Which of the following
interventions should the nurse include in the plan of care?
1. Fold the top of the stocking over neatly
2. Apply the stockings after the client is in a chair
3. Massage the client's legs once every 8 hr while the stockings are in place
4. Determine if the stockings are binding
-This ensures that antiembolic stockings are serving its purpose. It checks whether
the stockings are of the right fit. First 3 choices are not necessary.
2. A nurse on a medical surgical is performing medication reconciliation for a newly
admitted client. Which of the following should the nurse take?
1. Compare the prescription to the allergy history of the client
2. Compare the medication label to the provider's prescription on three occasions
before administration
3. Compare a list of common medications to treat a condition to the actual prescriptions
4. Compare for client's list of home medications to the admission prescriptions written
for the client
-This ensures that prescribed drugs do not cause harm to the patient due to drug
allergies. 2nd choice is wrong because you need to check for name of patient, drug,
dosage and do not necessarily have to do it 3x. 3rd and 4th choices are not necessary.
3. A community health nurse is receiving laboratory reports for a group of clients. The nurse
should identity that which of the following disorders is on the CDCs Nationally Notifiable
Conditions list?
1. Pediculosis capitis
2. bacterial vaginosis
3. respiratory syncytial virus
4. Lyme disease
-Lyme disease is only disease found on list.
4. A nurse is caring a client following application of a cast. Which of the following actions
should the nurse take first?
1. Place an ice pack over the cast
2. Position the casted extremity on a pillow
3. Palpate the pulse distal to the cast
4. Teach the client to keep the cast clean and dry
This check whether there is adequate blood flow to that extremity or not. Distal
pulses signify adequate blood flow. If cast is impeding blood flow, it could
compromise the extremity. So this must be the priority nursing action before
anything else.
,5. A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which
of the following actions by the newly licenses nurse requires interventions by the staff
nurse?
1. Applies suction for 15 seconds
2. Encourages the client to cough during suctioning
3. Wait for 2 min between suctions
4. Inserts the catheter without applying suction
1st is correct because you must suction for 10-15 seconds (so it isn't the answer)
2nd is correct because encouraging patient to cough displaces secretions towards
upper airway, allowing it to be suctioned and removed, promoting clearance of
airway (so it isn't the answer)
3rd is incorrect because you must allow patient to rest for 20-30 seconds but waiting 2
mins between suctions is too long. You however must always allow patient to rest
between suctioning to allow them to oxygenate and rest. (the answer)
4th is correct because you must not suction while inserting catheter. This ensures
proper placement and insertion of the catheter. You must insert and suction while
slowly pulling it out (so it isn't the answer)
6. A nurse is working with a client who has an anxiety disorder and is in in the orientation
phase of the therapeutic relationship. Which of the following statements should the nurse
make during this phase?
1. Let's talk about how you can change your response to stress
2. Let me show you simple relation exercise to manage stress
3. We should establish our roles in the initial session
4. We should discuss resource to implement in your daily life
3rd is the answer because since nurse-client relationship is in orientation phase, it is
important to establish and orient the patient on their roles and goals. Other choices
are incorrect because they are more focused on the interventional aspect and not on
the orientation phase.
7. A nurse is caring for a client who is at 11 weeks of gestation. Which of the following
immunization should the nurse recommend?
a. influenza
b. human Papillomavirus
C. Measles, mumps, and rubella
d. varicella
A is the answer as it is the recommended vaccine for the patient's age. B is wrong
because it is usually administered/initiated at age 9-14. While C and D are also wrong
because they are usually given at 12-18 months.
8. A home health nurse is preparing to make a initial visit to a family following a referral from
a local provider. Identify the sequence of step the nurse should take when conducting a
home visit. Placing them in the order of performance. Use all steps
, 1. Discus plans for future visits with the family
2. Clarify the reason for the referral with the provider's office
3. Record information about the home visit according to agency policy
4. Identify family needs and interventions using the nursing process
5. Contact the family to determine availability and readness to make an appointment
4->5->2->3->1
You must first assess what the family's needs are. After that, make sure that they are
cooperative and agree with the intervention you have planned. When they are ready
to make an appointment, you must then clarify the reason for referral with provider's
office. From there, you record or document information about your home visit. Then
finally discuss plans with family for future visits to check and assess whether your
intervention was successful and goals were met.
A.
9. A nurse is planning care for a client who has an L4 spinal cord injury. Which of the
following interventions to prevent skin breakdown should the nurse include in the plan of
care?
1. Massage reddened area over bony prominences
2. Provide a hight fiber diet for the client
3. Ask the client to shift his weight every 20 min while sitting in a chair
4. Maintain the head of bed at 45 degree angle
This allows adequate tissue perfusion, decreasing the risk of skin breakdown.
Massaging reddened area is incorrect because this only puts more pressure and
friction on already irritated are, increasing risk of skin breakdown. High fiber diet can
help with defecation but does not contribute to the risk of skin breakdown. Also
maintaining the head of bed at 45 degrees ensures proper oxygenation and breathing
but does not apply to the problem.
10. A nurse is preparing to administer vancomycin IV to an adult client. The client asks the
nurse if the medication can be given 2 hr earlier. Which of the following statements should
the nurse makes?
1. I have up to 2 hours after usual schedule time to give you this medication
2. I can start the medication 30 min earlier
3. I can infuse the medication as a faster rate
4. I can adjust the time and schedule for when it's convenient for you
2nd choice is correct because it isn't too early or too late to the previous or next
dose which allows proper spacing. 1st choice is wrong because it is too late. 3rd
choice is wrong because infusing antibiotics at a faster rate is very painful
especially since it is given via IV, and also dosing is properly calculated.
Dosage and rate of infusion cannot be altered. Also 4th choice is incorrect
because it is not feasible and will make patient used to delaying treatment. An
adequate treatment schedule should be implemented.
11. A nurse is planning care for a client who sustained a major burn over 20% of the body.
Which of the following interventions should the nurse include is important to support the
client's nutritional requirements?
1. A nurse is caring for a client who is wearing antiembolic stockings. Which of the following
interventions should the nurse include in the plan of care?
1. Fold the top of the stocking over neatly
2. Apply the stockings after the client is in a chair
3. Massage the client's legs once every 8 hr while the stockings are in place
4. Determine if the stockings are binding
-This ensures that antiembolic stockings are serving its purpose. It checks whether
the stockings are of the right fit. First 3 choices are not necessary.
2. A nurse on a medical surgical is performing medication reconciliation for a newly
admitted client. Which of the following should the nurse take?
1. Compare the prescription to the allergy history of the client
2. Compare the medication label to the provider's prescription on three occasions
before administration
3. Compare a list of common medications to treat a condition to the actual prescriptions
4. Compare for client's list of home medications to the admission prescriptions written
for the client
-This ensures that prescribed drugs do not cause harm to the patient due to drug
allergies. 2nd choice is wrong because you need to check for name of patient, drug,
dosage and do not necessarily have to do it 3x. 3rd and 4th choices are not necessary.
3. A community health nurse is receiving laboratory reports for a group of clients. The nurse
should identity that which of the following disorders is on the CDCs Nationally Notifiable
Conditions list?
1. Pediculosis capitis
2. bacterial vaginosis
3. respiratory syncytial virus
4. Lyme disease
-Lyme disease is only disease found on list.
4. A nurse is caring a client following application of a cast. Which of the following actions
should the nurse take first?
1. Place an ice pack over the cast
2. Position the casted extremity on a pillow
3. Palpate the pulse distal to the cast
4. Teach the client to keep the cast clean and dry
This check whether there is adequate blood flow to that extremity or not. Distal
pulses signify adequate blood flow. If cast is impeding blood flow, it could
compromise the extremity. So this must be the priority nursing action before
anything else.
,5. A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which
of the following actions by the newly licenses nurse requires interventions by the staff
nurse?
1. Applies suction for 15 seconds
2. Encourages the client to cough during suctioning
3. Wait for 2 min between suctions
4. Inserts the catheter without applying suction
1st is correct because you must suction for 10-15 seconds (so it isn't the answer)
2nd is correct because encouraging patient to cough displaces secretions towards
upper airway, allowing it to be suctioned and removed, promoting clearance of
airway (so it isn't the answer)
3rd is incorrect because you must allow patient to rest for 20-30 seconds but waiting 2
mins between suctions is too long. You however must always allow patient to rest
between suctioning to allow them to oxygenate and rest. (the answer)
4th is correct because you must not suction while inserting catheter. This ensures
proper placement and insertion of the catheter. You must insert and suction while
slowly pulling it out (so it isn't the answer)
6. A nurse is working with a client who has an anxiety disorder and is in in the orientation
phase of the therapeutic relationship. Which of the following statements should the nurse
make during this phase?
1. Let's talk about how you can change your response to stress
2. Let me show you simple relation exercise to manage stress
3. We should establish our roles in the initial session
4. We should discuss resource to implement in your daily life
3rd is the answer because since nurse-client relationship is in orientation phase, it is
important to establish and orient the patient on their roles and goals. Other choices
are incorrect because they are more focused on the interventional aspect and not on
the orientation phase.
7. A nurse is caring for a client who is at 11 weeks of gestation. Which of the following
immunization should the nurse recommend?
a. influenza
b. human Papillomavirus
C. Measles, mumps, and rubella
d. varicella
A is the answer as it is the recommended vaccine for the patient's age. B is wrong
because it is usually administered/initiated at age 9-14. While C and D are also wrong
because they are usually given at 12-18 months.
8. A home health nurse is preparing to make a initial visit to a family following a referral from
a local provider. Identify the sequence of step the nurse should take when conducting a
home visit. Placing them in the order of performance. Use all steps
, 1. Discus plans for future visits with the family
2. Clarify the reason for the referral with the provider's office
3. Record information about the home visit according to agency policy
4. Identify family needs and interventions using the nursing process
5. Contact the family to determine availability and readness to make an appointment
4->5->2->3->1
You must first assess what the family's needs are. After that, make sure that they are
cooperative and agree with the intervention you have planned. When they are ready
to make an appointment, you must then clarify the reason for referral with provider's
office. From there, you record or document information about your home visit. Then
finally discuss plans with family for future visits to check and assess whether your
intervention was successful and goals were met.
A.
9. A nurse is planning care for a client who has an L4 spinal cord injury. Which of the
following interventions to prevent skin breakdown should the nurse include in the plan of
care?
1. Massage reddened area over bony prominences
2. Provide a hight fiber diet for the client
3. Ask the client to shift his weight every 20 min while sitting in a chair
4. Maintain the head of bed at 45 degree angle
This allows adequate tissue perfusion, decreasing the risk of skin breakdown.
Massaging reddened area is incorrect because this only puts more pressure and
friction on already irritated are, increasing risk of skin breakdown. High fiber diet can
help with defecation but does not contribute to the risk of skin breakdown. Also
maintaining the head of bed at 45 degrees ensures proper oxygenation and breathing
but does not apply to the problem.
10. A nurse is preparing to administer vancomycin IV to an adult client. The client asks the
nurse if the medication can be given 2 hr earlier. Which of the following statements should
the nurse makes?
1. I have up to 2 hours after usual schedule time to give you this medication
2. I can start the medication 30 min earlier
3. I can infuse the medication as a faster rate
4. I can adjust the time and schedule for when it's convenient for you
2nd choice is correct because it isn't too early or too late to the previous or next
dose which allows proper spacing. 1st choice is wrong because it is too late. 3rd
choice is wrong because infusing antibiotics at a faster rate is very painful
especially since it is given via IV, and also dosing is properly calculated.
Dosage and rate of infusion cannot be altered. Also 4th choice is incorrect
because it is not feasible and will make patient used to delaying treatment. An
adequate treatment schedule should be implemented.
11. A nurse is planning care for a client who sustained a major burn over 20% of the body.
Which of the following interventions should the nurse include is important to support the
client's nutritional requirements?
