V1, V2, V3, V4, V5, V6, V7 EXAM
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During the last 30 days, an elderly client has exhibited a progressively decreasing appetite, is
spending increasing amounts of daytime hours in bed and refuses to participate in planned
daytime activities. Which action should the practical nurse take?
Record the findings and report the symptoms to the charge nurse
, A male client who has been diagnosed with schizophrenia is withdrawn, isolates himself in
the day room, and answers question with one or two word responses. This morning, the
practical nurse observes that he is diaphoretic and is pacing in the hall. Which intervention is
most important to the PN to implement?
Measure appropriate vital signs
At 1200, the practical nurse learns that a client's 0900 dose of an anticonvulsant was not
given. The next scheduled dose is at 2100. Which action should the PN take?
Administer the missed dose as soon as possible
The practical nurse is caring for a client who had a total laryngectomy, left radical neck
dissection, and tracheostomy. The client is receiving nasogastric tube feedings via an enteral
pump. Today the rate of feeding is increased from 50 ml/hr to 75 ml/her. What parameter
should the PN use to evaluate the client's tolerance to the rate of the feeding?
Gastric residual volumes
The practical nurse is caring for a client whose urine drug screen is positive for cocaine,
Which behavior is this client likely to exhibit during cocaine withdrawal
Powerful craving for more
The PN administered darbepoetin alfa to a client with Chronic Kidney Disease(CKD). Which
serum laboratory value should the PN monitor to gather the effectiveness of this drug?
Phosphorous
The PN observes an UAP bathing a bedfast client with the bed in the high position. Which
action should the PN take?
Instruct the UAP to lower the bed for safety
Thirty minutes after receiving IV morphine, a postoperative client continues yes to rate pain
as 7 on 10 point scale. Which action should the PN implement first
Implement complimentary pain relief methods
The PN is caring for a laboring client whose last sterile vaginal examination revealed the
cervix was 3 cm dilated, 50% effaced, and the presenting part was 0 station. An hour later,
the client tells the PN that she wants to go the bathroom. Which action is most important for
the PN to implement?
Request nurse to check client's cervical dilation
, The PN identifies an electrolyte imbalance, exhibited changes in mental status, and an
elevated blood pressure for a client with progressive heart disease. Which intervention should
the PN implement first?
Evaluate for muscle cramping
The PN is caring for an older client who was informed about the diagnosis of terminal cancer
two days ago. Which intervention wouldbe most helpful for the client's spouse at this time?
Information about palliative and hospice care services
The PN is caring for a child who was admitted after experiencing a generalized tonic-clonic
seizure. When witnessing the child begin to seize again, which actions should the PN
implement immediately? Select all that apply
A. Observe the progression of the seizure B. Loosen clothing around the neck
C. Pad the side rails with pillows
The HCP prescribes heparin 4,500 units subcutaneously once daily. The medication is
available in a vial that contains heparin 10,000 units/mL. How many mL should the PN
administer? -
0.45
The UAP is caring for a male resident of a long-term care facility who has an external urinary
catheter. Which finding should the PN instruct the UAP to report immediately?
Swollen and discolored menial shaft
The practical nurse enters a male client's room to administer routine morning medications,
and the client is on the phone. Which action is best for the PN to take?
Wait for the client to excuse himself from the telephone conversation, and observe the client
taking the medication
A client is admitted to the postoperative surgical unit with two test tubes after a left
lobectomy. The ON observed that the chambers are set at the prescribed suction of 20 cm
water pressure and tidying occurs with respirations and bubbling. What action should the PN
implement?
Maintain system integrity to promote lung reexpansion
The mother of a 9-month-child who was diagnosed with respiratory syncytial virus yesterday
calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a
friend's child for the following day. Which response should the PN provide the mother?
, Do not expose other children as the virus is very contagious even without direct contact
The practical nurse is assisting the nurse with the admission of a young adult female Korean
exchange student with acute abdominal pain. Although the client has been able to easily
answer questions, when asked about sexual activity, she looks away. What action should the
PN take
Watch the client's response when asked a different question
During immediate postoperative period following a total hip placement, which intervention is
most important for the PN to implement?
Keep client's hip aligned with knees abducted
A client confides to the PN that the client has been substituting herbal supplements for high
blood pressure instead of the prescribed medication. How should the PN respond first?
Ask the client's reason for choosing to take herbs instead of prescribed drugs
The PN is assigned to administer medications in a long term care facility. A disoriented
resident has no identification band or picture. What is the best nursing action for the PN to
take prior administering the medications this resident?
Confirm the room and bed numbers with those on the medication record
An adult client who weighs 150 pounds has partial-thickness and full-thickness burns over
40% of the body from a house fire. After admission, which observation is most important for
the practical nurse to report immediately?
Urinary Output of 20ml/hr
A 12-year-old child is receiving a blood transfusion per infusion pump and begins to
complain of "itchy" skin 15 minutes after the unit of blood is started. The child appears
flushed. What action should the practical nurse take first
Stop the transfusion
A PN is competing a focused assessment of an older adult's skin. The PN notes a crusted 0.7
cm lesion on the client's forehead. Which action should the PN take in response to this
finding?
Apply a warm compress to remove the crusted area
While taking the vital signs of an older male client who takes psychotropic medications, the
PN notes that he has uncontrollable hand movements and is excessively blinking his eyes.
Which information in the client's medical record should the PN review?
History of Parkinson's disease