When preparing to administer a prescribed medication to a homeless client at a community psychiatric
clinic. The client tells the nurse that the usual dosage taken is different from the dose the nurse is giving.
Which action should the nurse take?
A) Inform the client that he may refuse the medication and document whether or not the client takes it.
B) Withhold the medication until the dosage can be confirmed.
C) Explain to the client that the dosage has been changed.
D) Tell the client to take the medication then verify the dosage at the next healthcare team meeting. -
CORRECT ANSWERS B) Withhold the medication until the dosage can be confirmed.
The charge nurse is making assignments for one practical nurse and three registered nurses who are
caring for neurologically compromised clients. Which client with which change in status is best to assign
to the PN?
A) Subdural hematoma whose blood pressure changed from 150/80 to 170/60.
B) Viral meningitis whose temperature change from 101 S to 102F.
C) Diabetic keto acidosis who is Glasgow coma scale score changed from 10 to 7.
D) Myxedema, whose blood pressure change from 80/50 to 70/40. - CORRECT ANSWERS B) Viral
meningitis whose temperature change from 101 S to 102F.
The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi
organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important
for the nurse to include in the plan of care?
A) Maintain strict intake and output.
B) Keep head of bed raised 45°.
C) Excess warmth of extremities.
D) Monitor blood glucose level. - CORRECT ANSWERS A) Maintain strict intake and output.
,And adolescent client is admitted to the hospital because of writing a suicide note to a teacher at school.
On the second day of hospitalization, the nurse asked the client to meet with the treatment team. After
the team meeting, the client leaves in tears and goes to their room. Which nursing intervention is best?
A) Let the client rest quietly in their room for a while.
B) Explore the clients goals and desire for treatment.
C) Ask the treatment team about the clients behavior.
D) Go to the clients room and ask what happened. - CORRECT ANSWERS D) Go to the clients room and
ask what happened.
The healthcare provider prescribes dalteparin 200 units per kilogram subcutaneous once a day for a
client who weighs 154 pounds. The medication is available and 25,000 units per milliliter vial. How many
milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the
nearest 10th.) - CORRECT ANSWERS 0.6
NGN: The client is a 49-year-old male who reports flu like symptoms including fever and chest congestion
for four days. He came to the emergency department last night when he was having more difficulty
breathing he has a history of 1/2 pack a day cigarette smoking for 20 years. He has no significant medical
or surgical history.
Which two orders should the nurse complete first?
A) Sputum culture.
B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
D) Chest x-ray.
E) Acetominophen 350 mg PO every six hours for temperature control.
F) Run 0.9% sodium chloride IV infusion at 150 mL per hour.
G) Start peripheral IV.
H) NPO. - CORRECT ANSWERS B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
,NGN: 0330: place the client on a cardio respiratory monitor, NPO, sputum culture, start a peripheral IV
infusion, start oxygen 3 L per minute via nasal cannula, begin 0.9% sodium chloride IV infusion at 150 mL
per hour, acetaminophen 350 mg PO every six hours for temperature.
To start the client on oxygen as ordered which items should the nurse collects from the supply room?
SATA
A) humidifier bottle.
B)Suction canister.
C)Sterile water.
D) Nasal cannula.
E) Flow meter.
F) Lambs wool.
G) Tape. - CORRECT ANSWERS D) Nasal cannula.
E) Flow meter.
NGN: states, I am feeling extremely anxious right now. The client has decreased breath sounds in the left
lower low. His mucus membranes are dry. He has a productive cough with thick, yellow secretions. His
capillary refill is four seconds. Vital signs, temperature 100.2. Heart rate 101 bpm, respiratory rate 28
breaths per minute, blood pressure 145/89, oxygen saturation 90% on room air.
(for each body system click to specify the assessment findings that indicates hypoxia)
Cardiovascular: heart rate 100 bpm, capillary refill for seconds, blood pressure 145/89.
Neurological: anxious, awake and alert, restless.
Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm, productive cough. - CORRECT
ANSWERS Cardiovascular: capillary refill for seconds, blood pressure 145/89.
Neurological: anxious, restless.
Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm.
NGN: The client is a 49-year-old male who reports flu like symptoms including fever and chest congestion
for four days. He came to the emergency department last night when he was having more difficulty
breathing he has a history of 1/2 pack a day cigarette smoking for 20 years. He has no significant medical
or surgical history.
, The nurse should place the client in a _______________ position to promote _____________. -
CORRECT ANSWERS Semi-Fowler , lung expansion.
NGN: Orders: 0330: place the client on a cardio respiratory monitor, NPO, sputum culture, start a PIV,
start oxygen 3L via nasal cannula, normal saline 150 ML per hour, acetaminophen 350mg PO every six
hours for temp greater than 101F, chest x-ray.
0500: Oxygen 8Lvia simple facemask, titrate to keep oxygen saturation greater than 94%.
(mark whether the statements by the new grad nurse indicate understanding or no understanding of the
use of facemask in the care of this client)
-I should clean the facemask once per shift.
-The client should take a 1 to 2 minute break from the facemask each hour.
-I should put gauze under the elastic straps over the ears.
-I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation greater than 94%.
-The mask should cover only the mouth and leave the nose open for expiration.
-I should place the mask first over the nose and then cover the mouth. - CORRECT ANSWERS -I should
clean the facemask once per shift. (UNDERSTANDING)
-The client should take a 1 to 2 minute break from the facemask each hour. (NOT UNDERSTANDING)
-I should put gauze under the elastic straps over the ears. (NOT UNDERSTANDING ????)
-I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation greater than 94%.
(UNDERSTANDING)
-The mask should cover only the mouth and leave the nose open for expiration. (NOT UNDERSTANDING)
-I should place the mask first over the nose and then cover the mouth. (UNDERSTANDING)
NGN: Nurses Notes: 0400, the client is awake and alert but restless. He states I am feeling extremely
anxious right now. The client has decreased breath sounds in the left lower lobe. His mucus membranes
are dry. He has a productive cough with thick, yellow secretions. His capillary refill is four seconds. Heart
rate 101 BPM, oxygen saturation 90%. Blood pressure 145/89, temperature 100.2 F, respiratory rate 28
BPM.
0500: Placedthe client in semi-Fowlers position. No improvement in oxygen saturation on 3L nasal
cannula...
clinic. The client tells the nurse that the usual dosage taken is different from the dose the nurse is giving.
Which action should the nurse take?
A) Inform the client that he may refuse the medication and document whether or not the client takes it.
B) Withhold the medication until the dosage can be confirmed.
C) Explain to the client that the dosage has been changed.
D) Tell the client to take the medication then verify the dosage at the next healthcare team meeting. -
CORRECT ANSWERS B) Withhold the medication until the dosage can be confirmed.
The charge nurse is making assignments for one practical nurse and three registered nurses who are
caring for neurologically compromised clients. Which client with which change in status is best to assign
to the PN?
A) Subdural hematoma whose blood pressure changed from 150/80 to 170/60.
B) Viral meningitis whose temperature change from 101 S to 102F.
C) Diabetic keto acidosis who is Glasgow coma scale score changed from 10 to 7.
D) Myxedema, whose blood pressure change from 80/50 to 70/40. - CORRECT ANSWERS B) Viral
meningitis whose temperature change from 101 S to 102F.
The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi
organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important
for the nurse to include in the plan of care?
A) Maintain strict intake and output.
B) Keep head of bed raised 45°.
C) Excess warmth of extremities.
D) Monitor blood glucose level. - CORRECT ANSWERS A) Maintain strict intake and output.
,And adolescent client is admitted to the hospital because of writing a suicide note to a teacher at school.
On the second day of hospitalization, the nurse asked the client to meet with the treatment team. After
the team meeting, the client leaves in tears and goes to their room. Which nursing intervention is best?
A) Let the client rest quietly in their room for a while.
B) Explore the clients goals and desire for treatment.
C) Ask the treatment team about the clients behavior.
D) Go to the clients room and ask what happened. - CORRECT ANSWERS D) Go to the clients room and
ask what happened.
The healthcare provider prescribes dalteparin 200 units per kilogram subcutaneous once a day for a
client who weighs 154 pounds. The medication is available and 25,000 units per milliliter vial. How many
milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the
nearest 10th.) - CORRECT ANSWERS 0.6
NGN: The client is a 49-year-old male who reports flu like symptoms including fever and chest congestion
for four days. He came to the emergency department last night when he was having more difficulty
breathing he has a history of 1/2 pack a day cigarette smoking for 20 years. He has no significant medical
or surgical history.
Which two orders should the nurse complete first?
A) Sputum culture.
B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
D) Chest x-ray.
E) Acetominophen 350 mg PO every six hours for temperature control.
F) Run 0.9% sodium chloride IV infusion at 150 mL per hour.
G) Start peripheral IV.
H) NPO. - CORRECT ANSWERS B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
,NGN: 0330: place the client on a cardio respiratory monitor, NPO, sputum culture, start a peripheral IV
infusion, start oxygen 3 L per minute via nasal cannula, begin 0.9% sodium chloride IV infusion at 150 mL
per hour, acetaminophen 350 mg PO every six hours for temperature.
To start the client on oxygen as ordered which items should the nurse collects from the supply room?
SATA
A) humidifier bottle.
B)Suction canister.
C)Sterile water.
D) Nasal cannula.
E) Flow meter.
F) Lambs wool.
G) Tape. - CORRECT ANSWERS D) Nasal cannula.
E) Flow meter.
NGN: states, I am feeling extremely anxious right now. The client has decreased breath sounds in the left
lower low. His mucus membranes are dry. He has a productive cough with thick, yellow secretions. His
capillary refill is four seconds. Vital signs, temperature 100.2. Heart rate 101 bpm, respiratory rate 28
breaths per minute, blood pressure 145/89, oxygen saturation 90% on room air.
(for each body system click to specify the assessment findings that indicates hypoxia)
Cardiovascular: heart rate 100 bpm, capillary refill for seconds, blood pressure 145/89.
Neurological: anxious, awake and alert, restless.
Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm, productive cough. - CORRECT
ANSWERS Cardiovascular: capillary refill for seconds, blood pressure 145/89.
Neurological: anxious, restless.
Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm.
NGN: The client is a 49-year-old male who reports flu like symptoms including fever and chest congestion
for four days. He came to the emergency department last night when he was having more difficulty
breathing he has a history of 1/2 pack a day cigarette smoking for 20 years. He has no significant medical
or surgical history.
, The nurse should place the client in a _______________ position to promote _____________. -
CORRECT ANSWERS Semi-Fowler , lung expansion.
NGN: Orders: 0330: place the client on a cardio respiratory monitor, NPO, sputum culture, start a PIV,
start oxygen 3L via nasal cannula, normal saline 150 ML per hour, acetaminophen 350mg PO every six
hours for temp greater than 101F, chest x-ray.
0500: Oxygen 8Lvia simple facemask, titrate to keep oxygen saturation greater than 94%.
(mark whether the statements by the new grad nurse indicate understanding or no understanding of the
use of facemask in the care of this client)
-I should clean the facemask once per shift.
-The client should take a 1 to 2 minute break from the facemask each hour.
-I should put gauze under the elastic straps over the ears.
-I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation greater than 94%.
-The mask should cover only the mouth and leave the nose open for expiration.
-I should place the mask first over the nose and then cover the mouth. - CORRECT ANSWERS -I should
clean the facemask once per shift. (UNDERSTANDING)
-The client should take a 1 to 2 minute break from the facemask each hour. (NOT UNDERSTANDING)
-I should put gauze under the elastic straps over the ears. (NOT UNDERSTANDING ????)
-I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation greater than 94%.
(UNDERSTANDING)
-The mask should cover only the mouth and leave the nose open for expiration. (NOT UNDERSTANDING)
-I should place the mask first over the nose and then cover the mouth. (UNDERSTANDING)
NGN: Nurses Notes: 0400, the client is awake and alert but restless. He states I am feeling extremely
anxious right now. The client has decreased breath sounds in the left lower lobe. His mucus membranes
are dry. He has a productive cough with thick, yellow secretions. His capillary refill is four seconds. Heart
rate 101 BPM, oxygen saturation 90%. Blood pressure 145/89, temperature 100.2 F, respiratory rate 28
BPM.
0500: Placedthe client in semi-Fowlers position. No improvement in oxygen saturation on 3L nasal
cannula...
