The nurse has completed the diet teaching of a male client who is being discharged follow-
ing treatment of a leg wound. A high protein diet is encouraged to promote wound healing.
Which lunch choice by the client indicates that the teaching was effective?
A. A peanut butter sandwich with soda and cookies.
B. A tunafish sandwich with chips and ice cream.
C. A salad with three kinds of lettuce and fruit.
D. Vegetable soup, crackers, and milk. - ANSWER Answer
B. A tunafish sandwich with chips and ice cream.
Rationale
(B) contains the highest amount of protein. Four ounces of tuna contains 11 g of protein,
and ice cream 5 g of protein per cup. Chips are a fat with virtually no protein value. (A) con-
tains 4 grams of protein per tablespoon. (C) contains only 1 gram of protein per 1 cup serv-
ing. (D) may have beef flavoring but it consist mostly of vegetables and would therefore be
low in protein.
The healthcare provider prescribes methylergonovine maleate for a postpartum client with
uterine atony. What findings should indicate to the nurse to withhold the next dose of the
medication?
A. Excessive lochia.
B. Saturation of more than one pad per hour.
C. Hypertension.
D. Difficulty locating the uterine fundus. - ANSWER Answer
C. Hypertension.
1
,Rationale
Methylergonovine, an ergot alkaloid, has vasoconstrictive effects that can exaggerate pri-
mary hypertension. The nurse should withhold the medication if the client's blood pressure
is elevated (C) and notify the healthcare provider. (A, B, and D) are signs of uterine atony and
are indications for the use of the medication.
The nurse discontinues a continuous IV heparin infusion for a male client on strict bed rest,
and is now preparing to administer the client's first dose of in enoxaparin (Lovenox). Prior to
giving this subcutaneous injection, which assessment finding requires additional interven-
tion by the nurse?
A. Current lab report indicates an aPTT at 1.5 times the client's control.
B. Several bruised areas are noted on the client's upper extremities bilaterally.
C. The client states that his right calf is aching, and wants pain medication.
D. The spouse is assisting the client who is shaving with an electric razor. - ANSWER An-
swer
C. The client states that his right calf is aching, and wants pain medication.
Rationale
A calf ache severe enough for the client to request pain medication (C) should be reported to
the healthcare provider immediately so that an adjustment in the anticoagulation therapy
can be made. Calf pain may be a sign of deep vein thrombosis indicative of ineffective anti-
coagulant heparin therapy. (A and B) are expected findings. Shaving with an electric razor is
recommended to reduce the possibility of bleeding (D) and does not require intervention.
While the nurse is providing morning care for a client with chronic obstructive pulmonary
disease (COPD), the client becomes very dyspneic and starts to panic. What action should
the nurse implement first?
A. Instruct the client to perform diaphragmatic breathing.
B. Use a calm voice to tell the client to breathe slowly.
2
,C. Administer two puffs of a metered-dose inhaler.
D. Assist the client to an upright position. - ANSWER Answer
D. Assist the client to an upright position.
Rationale
The nurse should first assist the client to an upright position (D), which allows the lungs to
expand fully. After this, the nurse can implement (A, B, and C) as needed.
A female client's estranged husband arrives at the hospital and demands that his wife have
no other visitors. The client becomes angry and insists that the estranged husband be barred
from visiting her. Which intervention should the nurse implement?
A. Obtain a prescription to allow client to dictate who can visit.
B. Request a multidisciplinary care conference to discuss husband's demands.
C. Have the hospital's medical-legal department meet with the client.
D. Encourage the client to speak with husband regarding his disruptive behavior. - AN-
SWER Answer
B. Request a multidisciplinary care conference to discuss husband's demands.
Rationale
A multi-disciplinary care conference involves the healthcare team to evaluate difficult situa-
tions that conflict with client safety and autonomy. During this conference, the client's
wishes regarding her health care decisions can be clarified to all team members. All other
options are not indicated.
The nurse working in a critical care unit is assigned the care of two clients, one with pneu-
monia who is being mechanically ventilated and the other who had a thoracotomy yesterday
and is complaining of incisional pain. What should the nurse to first?
A. Assess the level of consciousness and vital signs for both clients.
3
, B. Complete a head to toe assessment of the client with pneumonia.
C. Change the surgical dressing to observe the appearance of the incision.
D. Review the plan of care and the medications that are due for both clients. - ANSWER
Answer
A. Assess the level of consciousness and vital signs for both clients.
Rationale
Assessing the level of consciousness and vital signs for both clients (A) provides a quick
measurement of priority need. Before a complete assessment (B) is done on one client, the
nurse should at least do a quick assessment of the other client. Changing the dressing and
observing the incision (C) may be indicated, but only after both clients are quickly assessed.
Reviewing the plan of care and medications due for administration (D) should wait until the
nurse has evaluated both clients for any urgent clinical needs.
A client who received partial thickness (second degree) burns over the anterior surfaces of
both arms, legs, and chest in a burning vehicle collision receives a prescription for daily
dressing changes and therapeutic baths. The nurse determines that a hoist is required to
move the immobile client from a stretcher into the therapeutic bath. Which intervention
should the nurse implement first?
A. Obtain the hoist from the supply room.
B. Explain the procedure to the client.
C. Medicate the client with an analgesic.
D. Remove all bandages prior to moving the client. - ANSWER Answer
B. Explain the procedure to the client.
Rationale
Before implementing any new procedure, an explanation of the procedure should be pro-
vided (B). Bringing large pieces of equipment into the client's room (A), such as a mechanical
lift, may alarm the client if the procedure has not been explained. The client should be medi-
cated (C), but first explaining what is involved in the procedure helps prepare the client for
subsequent actions. Dressing bandages provide protection for the wounds and help
4
ing treatment of a leg wound. A high protein diet is encouraged to promote wound healing.
Which lunch choice by the client indicates that the teaching was effective?
A. A peanut butter sandwich with soda and cookies.
B. A tunafish sandwich with chips and ice cream.
C. A salad with three kinds of lettuce and fruit.
D. Vegetable soup, crackers, and milk. - ANSWER Answer
B. A tunafish sandwich with chips and ice cream.
Rationale
(B) contains the highest amount of protein. Four ounces of tuna contains 11 g of protein,
and ice cream 5 g of protein per cup. Chips are a fat with virtually no protein value. (A) con-
tains 4 grams of protein per tablespoon. (C) contains only 1 gram of protein per 1 cup serv-
ing. (D) may have beef flavoring but it consist mostly of vegetables and would therefore be
low in protein.
The healthcare provider prescribes methylergonovine maleate for a postpartum client with
uterine atony. What findings should indicate to the nurse to withhold the next dose of the
medication?
A. Excessive lochia.
B. Saturation of more than one pad per hour.
C. Hypertension.
D. Difficulty locating the uterine fundus. - ANSWER Answer
C. Hypertension.
1
,Rationale
Methylergonovine, an ergot alkaloid, has vasoconstrictive effects that can exaggerate pri-
mary hypertension. The nurse should withhold the medication if the client's blood pressure
is elevated (C) and notify the healthcare provider. (A, B, and D) are signs of uterine atony and
are indications for the use of the medication.
The nurse discontinues a continuous IV heparin infusion for a male client on strict bed rest,
and is now preparing to administer the client's first dose of in enoxaparin (Lovenox). Prior to
giving this subcutaneous injection, which assessment finding requires additional interven-
tion by the nurse?
A. Current lab report indicates an aPTT at 1.5 times the client's control.
B. Several bruised areas are noted on the client's upper extremities bilaterally.
C. The client states that his right calf is aching, and wants pain medication.
D. The spouse is assisting the client who is shaving with an electric razor. - ANSWER An-
swer
C. The client states that his right calf is aching, and wants pain medication.
Rationale
A calf ache severe enough for the client to request pain medication (C) should be reported to
the healthcare provider immediately so that an adjustment in the anticoagulation therapy
can be made. Calf pain may be a sign of deep vein thrombosis indicative of ineffective anti-
coagulant heparin therapy. (A and B) are expected findings. Shaving with an electric razor is
recommended to reduce the possibility of bleeding (D) and does not require intervention.
While the nurse is providing morning care for a client with chronic obstructive pulmonary
disease (COPD), the client becomes very dyspneic and starts to panic. What action should
the nurse implement first?
A. Instruct the client to perform diaphragmatic breathing.
B. Use a calm voice to tell the client to breathe slowly.
2
,C. Administer two puffs of a metered-dose inhaler.
D. Assist the client to an upright position. - ANSWER Answer
D. Assist the client to an upright position.
Rationale
The nurse should first assist the client to an upright position (D), which allows the lungs to
expand fully. After this, the nurse can implement (A, B, and C) as needed.
A female client's estranged husband arrives at the hospital and demands that his wife have
no other visitors. The client becomes angry and insists that the estranged husband be barred
from visiting her. Which intervention should the nurse implement?
A. Obtain a prescription to allow client to dictate who can visit.
B. Request a multidisciplinary care conference to discuss husband's demands.
C. Have the hospital's medical-legal department meet with the client.
D. Encourage the client to speak with husband regarding his disruptive behavior. - AN-
SWER Answer
B. Request a multidisciplinary care conference to discuss husband's demands.
Rationale
A multi-disciplinary care conference involves the healthcare team to evaluate difficult situa-
tions that conflict with client safety and autonomy. During this conference, the client's
wishes regarding her health care decisions can be clarified to all team members. All other
options are not indicated.
The nurse working in a critical care unit is assigned the care of two clients, one with pneu-
monia who is being mechanically ventilated and the other who had a thoracotomy yesterday
and is complaining of incisional pain. What should the nurse to first?
A. Assess the level of consciousness and vital signs for both clients.
3
, B. Complete a head to toe assessment of the client with pneumonia.
C. Change the surgical dressing to observe the appearance of the incision.
D. Review the plan of care and the medications that are due for both clients. - ANSWER
Answer
A. Assess the level of consciousness and vital signs for both clients.
Rationale
Assessing the level of consciousness and vital signs for both clients (A) provides a quick
measurement of priority need. Before a complete assessment (B) is done on one client, the
nurse should at least do a quick assessment of the other client. Changing the dressing and
observing the incision (C) may be indicated, but only after both clients are quickly assessed.
Reviewing the plan of care and medications due for administration (D) should wait until the
nurse has evaluated both clients for any urgent clinical needs.
A client who received partial thickness (second degree) burns over the anterior surfaces of
both arms, legs, and chest in a burning vehicle collision receives a prescription for daily
dressing changes and therapeutic baths. The nurse determines that a hoist is required to
move the immobile client from a stretcher into the therapeutic bath. Which intervention
should the nurse implement first?
A. Obtain the hoist from the supply room.
B. Explain the procedure to the client.
C. Medicate the client with an analgesic.
D. Remove all bandages prior to moving the client. - ANSWER Answer
B. Explain the procedure to the client.
Rationale
Before implementing any new procedure, an explanation of the procedure should be pro-
vided (B). Bringing large pieces of equipment into the client's room (A), such as a mechanical
lift, may alarm the client if the procedure has not been explained. The client should be medi-
cated (C), but first explaining what is involved in the procedure helps prepare the client for
subsequent actions. Dressing bandages provide protection for the wounds and help
4
