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