PROCTORED EXAM WITH CORRECT ANSWERS
A nurse is caring for a client who is 2 days postoperative following an above-the-
knee amputation. The client states he is experiencing a dull, burning pain in the
leg that was amputated. Which of the following actions should the nurse take to
treat the client's neuropathic pain?: Administer a beta-blocking medication to the
client.
(The nurse should administer a beta-blocking medication to the client. This
classification of medication has been shown to relieve the phantom limb pain
manifestations of constant dull and burning type pain.)
1. A newly licensed nurse asks a charge nurse where to find information about
scope of practice for registered nurses. Which of the following responses should
the charge nurse make?: "The state board of nursing can provide this information"
(each state develops a nurse practice act, which defines scope of practice for nurses
in that state. This practice act is available on the board of nursing website for each
state.)
2. A nurse is planning care to prevent a catheter-related bloodstream infection
for a client who is receiving IV fluid therapy. Which of the following
interventions should the nurse include in the plan?: Perform hand hygiene before
touching the IV tubing.
(The nurse should perform thorough hand hygiene before touching any part of
the infusion system or the client to reduce the risk of catheter-related blood stream
infections.)
3. A nurse is creating a plan of care for a client who is non-ambulatory and has
bladder and bowel incontinence. Which of the following interventions should
the nurse include to prevent skin breakdown?: Offer the client a glass of water
every two hour when repositioning.
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(The nurse should offer the client a glass of water every two hours on the clients
repositioning schedule. This helps prevent dehydration, which increases the risk
of skin breakdown.)
4. A nurse is teaching a young adult female client about health screening for
breast cancer. Which of the following statements by the client indicates an
understanding of breast self-examination (BSE)?: "I should expect to feel a firm
ridge along the bottom curve of each breast."
(The nurse should instruct the client at a firm ridge is expected along the bottom
curve of each breast. The client should be able to feel this area during the BSE.
Performing a BSE promotes breast self awareness so that the client knows how her
breast normally feel. The awareness increases the clients ability to identify changes
that require further evaluation.)
5. A nurse is caring for an adolescent who is in critical condition following a
motor vehicle crash which he was the passenger. The clients parent shout at the
nurse, asking why her son is dying instead of the driver. Which of the following
actions should the nurse take to provide emotional support to the parent?: Inform
the parent that anger is a natural response when dealing with loss. (The nurse
should identify that the parent is in the anger stage of grief. The nurse should assist
the parent to understand that anger is a natural response to loss and encourage her
to talk about her feelings.)
6. A nurse is teaching an older adult client about accessing electronic resources
for healthcare information on the internet. Which of the following statements
should the nurse include in the teaching?: "Websites ending in '.gov' are reliable
sites for obtaining health information from government agencies." (The nurse
should teach the client how to select reliable internet websites when researching
health care information. The nurse should identify that websites ending in '.gov
and '.edu' are considered reliable and credible sources for health information.
Websites ending in '.com' should not be used for researching credible healthcare
information.)
7. A nurse enters a clients room and finds the client lying on the floor. The
client states that on the way to the bathroom her "knee locked," causing her to
fall. Which of the following actions should the nurse take first?: Check the client
for injuries.
(The first action the nurse should take when using the nursing process is to assess
the client. The nurse should first check the client for injuries and measure vital signs
, to help determine physiologic stability. The nurse should also inform the provider
of the clients fall and of the assessment findings.)
8. A nurse is teaching a client who has rheumatoid arthritis about chronic pain
management. Which of the following statements by the client indicates an
understanding of the teaching?: "I should use a warm paraffin dip for my hands
and feet."
(The nurse should instruct the client to dip her hands and feet in warm paraffin
to alleviate pain and stiffness. The client can more easily perform hand and
finger exercises following the treatment.)
9. A community health nurse is planning prevention strategies for
hypertension among members of her community. The nurse should identify that
which of the following ethnic groups in the community is at greatest risk of
developing hypertension?: African American
(Evidence-based practice indicates that individuals of AA ethnicity have the highest
prevalence of hypertension. Therefore, the nurse should identify community
members of this ethnicity are at greatest risk of developing hypertension.)
10. A nurse is preparing to extinguish a small fire in a clients room. Which of
the following actions should the nurse take when using the fire extinguisher?:
Slide the pin on top of the fire extinguisher straight out.
(The nurse should pull the pin on top of the fire extinguisher to allow for use to
extinguish the fire.)
11. A nurse is preparing to administer intermittent external nutrition via a
clients NG tube. In which order should the nurse take the following actions?: 1.
Assist the client to an upright position.
2. Aspirate 5 mL of gastric contents.
3. Test the pH of gastric aspirate.
4. Measure gastric residual volume.
5. Flush the NG tube with 30 mL of water.
(First, the nurse should assist the client into high Fowler's position or raise the HOB
at least 30 degrees to help prevent aspiration. Then, the nurse should verify the
tubes placement by aspirating 5 mL of gastric contents and then testing the pH.
Then, the nurse should check for gastric residual volume. Excessive GRV is an
indication of delayed gastric emptying, which places the client at risk of aspiration
if additional formula is given. Finally, the nurse should flush the tubing with 30 mL
of water to ensure the tube is clear and patent.)