NCSBN NCLEX QUESTIONS

NCSBN NCLEX QUESTIONS A LPN complains to the charge nurse that an unlicensed assistive person (UAP) consistently leaves the work area untidy and does not restock supplies. What is the best initial response by the charge nurse? 1Write down potential solutions to the problems today by shift's end 2Add this concern to the agenda of the next unit meeting 3Assure the staff nurse that the complaint will be investigated 4Explore for further identification about the nature of the problem - correct answer -4 Explore for further identification about the nature of the problem The nurse assists with the reinforcement of information about breast self-examination to a group of college students. A female student asks when to perform the monthly exam. The appropriate reply by the nurse should include which statement? 1"Ovulation, or midcycle is the best time to detect changes." 2"Do the exam at the same time every month." 3"Right after the period, when your breasts are less tender." 4"The first of every month, because it will be easiest to remember." - correct answer -3 The nurse is caring for a 75 year-old client with type 2 diabetes mellitus. The client should be instructed to contact the outpatient clinic immediately if which findings are present? 1An open wound on the heel with minimal discomfort 2Occasional hiccups and sneezing 3Sustained insomnia and daytime fatigue 4Persistent dryness and itching of the perineal area - correct answer -1An open wound on the heel with minimal discomfortA pregnant woman has been advised to alter her diet during pregnancy by increasing the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet choice would best meet the woman's needs? 1. 1 cup of macaroni, three-fourths cup of peas, glass whole milk, medium pear 2. Scrambled egg, hash browned potatoes, one-half glass of buttermilk, large nectarine 3. 3 oz. chicken, one-half cup of corn, lettuce salad, small banana4. Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries - correct answer -4. Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries - A nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness should the nurse recognize as being associated with an increased the risk for the development of Reye's syndrome? 1. Varicella 2. Meningitis 3. Hepatitis 4. Rubeola - correct answer -1. Varicella - A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The nurse comments to a colleague: "I wonder if he has any idea how ridiculous he looks - he's a grown man!" The nurse's comment is an example of what type of attitude? 1. Prejudice 2. Ethnocentrism 3. Discrimination 4. Stereotyping - correct answer -1. PrejudiceA nursing student asks the licensed practical nurse (LPN) to explain the forces that drive health care reform. When responding to the student's question, what information should the nurse emphasize? 1. Increased competition between health care insurers 2. Increase in health care spending that's growing faster than the economy 3. Increase in the population who have health insurance 4. Increase in spending for end-of-life treatment - correct answer -2 A child is admitted to the unit with the suspected diagnosis of pertussis (whooping cough). What is the priority nursing intervention for this child? 1. Maintain hydration and encourage fluids 2. Implement droplet precautions 3. Monitor respiratory rate and oxygen saturation 4. Anti- infective therapy - correct answer -2A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the registered nurse (RN) charge nurse? 1Complaints for the feeling of pulling on the urinary catheter 2Light, pink to clear urine 3Occasional suprapubic cramping 4Minimal drainage into the urinary collection bag - correct answer -4Minimal drainage into the urinary collection bag A nurse is caring for a woman two hours after a vaginal delivery. Documentation indicates that the membranes ruptured 36 hours prior to delivery. Which of these nursing diagnoses should the nurse expect the charge nurse to list as a priority at this time? 1Risk for fluid volume deficit 2Risk for excessive bleeding 3Risk for infection - 4Altered tissue perfusion - correct answer -3 A 14 month-old child ingests a half a bottle of baby aspirin (81 mg) tablets. Which finding should a nurse expect to see in the child? 1Hypothermia 2Nausea and vomiting 3Hypoventilation 4Bradycardia - correct answer -2 A school nurse monitors a child with a history of tonic-clonic seizures. The school nurse should inform teachers that if the child falls to the floor and experiences a seizure while in the classroom, which of the following would be the most important action to take during the seizure? 1Place the hands or a folded blanket under the head of the child 2Provide privacy as much as possible to minimize frightening the other children 3Move any chairs or desks at least three feet away from the child 4Note the sequence of movements with the time lapse of the event - correct answer -1Place the hands or a folded blanket under the head of the child -A client is admitted with diagnosis of a right upper lobe infiltrate and to rule out active tuberculosis (TB). Which type of precautions will be needed for this client? 1Droplet 2Contact 3Standard 4Airborne - correct answer -4 A client has had a positive reaction to purified protein derivative (PPD). Which statement made by the client suggests the client understands the teaching by the registered nurse (RN)? 1"I have active tuberculosis." 2"I have been exposed to mycobacterium tuberculosis." 3"I have never been infected with mycobacterium tuberculosis." 4"I have never had tuberculosis." - correct answer -2 A nurse is caring for a client with pneumococcal pneumonia. Which breath sounds would the nurse expect to disappear as the client responds to the antibiotic treatment? 1Wheezes 2Friction rubs 3Rhonchi 4Diminished sounds - correct answer -3 A young adult seeks treatment in an outpatient mental health center. The client tells a nurse, "I am a government official and spies are following me." Upon further questioning, the client reveals that warnings must be heeded to prevent nuclear war. What is the initial therapeutic approach that the nurse should use? 1Listen quietly without comment 2Ask for further information on the spies 3Confront the client about the delusions 4Contact security for potential safety concerns - correct answer -1Listen quietly without comment - Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse use to evaluate the effectiveness of this treatment? 1Less jaundice2Increased appetite 3Decreased lethargy 4Less edema - correct answer -3 The LPN is unsure about an assignment by the charge nurse to hang an intravenous (IV) infusion that contains potassium. What resource should the LPN check first to determine if LPNs can administer IV medications? 1Employer policy and procedures manuals 2Nursing faculty from a local nursing program 3The nurse practice act of the state in which the practice takes place 4American Nurses Association (ANA) professional standards - correct answer -3 The nurse is assisting with the delivery of a newborn infant. What is the priority nursing intervention for a normal newborn immediately after delivery? 1Dry off infant with a warm blanket or towel 2Apply identification bracelets 3Assign the one-minute APGAR score 4Obtain vital signs - correct answer -1Dry off infant with a warm blanket or towel - The registered nurse is teaching a childbirth education class about postpartum depression. Which statement, made by a class member, indicates that more teaching is needed? 1"I will make an effort to talk with someone about my feelings if I start to feel overwhelmed." 2"It's common for women with postpartum depression to have delusions about the infant." 3"Women with postpartum depression have feelings of guilt and worthlessness." 4"I may experience postpartum depression up to a year after delivery." - correct answer -2 The nurse is reinforcing information about the side effects of fluoxetine to a client. Which group of findings should be included? 1Diarrhea, dry mouth, weight loss, reduced libido 2Tachycardia, blurred vision, hypotension, anorexia 3Orthostatic hypotension, vertigo, reactions to tyramine, nausea 4Photosensitivity, seizures, edema, hyperglycemia - correct answer -1Diarrhea, dry mouth, weight loss, reduced libidoA client has a diagnosis of heart failure. Which intervention is most important for the nurse to implement prior to the administration of digoxin? 1Use the pulse reading from the electronic blood pressure device 2Take a radial pulse, counting for a full 60 seconds 3Check for a pulse deficit at least twice with another nurse 4Assess the apical pulse, counting for a full 60 seconds - correct answer -4Assess the apical pulse, counting for a full 60 seconds - A client diagnosed with bipolar disorder refuses to take the prescribed medication. Which is the most therapeutic response by a nurse to the client's refusal of the medication? 1"You need to take your medicine. This is how you get better." 2"What is it about the medicine that you don't like?" 3"I can see that you are uncomfortable right now; let's talk about it tomorrow." 4"If you refuse your medicine, tell me how do you think you will get better?" - correct answer -2 A parent expresses frustration and anger about the toddler constantly saying "no" and refusing to follow directions. The nurse should help the parent understand that this behavior meets which developmental need? 1Self-esteem 2Initiative 3Independence 4Trust - correct answer -3 The LPN is assisting the RN to provide care for a client diagnosed with a traumatic brain injury. Using the Glasgow Coma Scale, when the client does not obey verbal commands to move, which technique will the RN use to evaluate motor function? 1Squeeze the trapezius muscle firmly 2Lift the client's arm and observe for pronation and drift 3Apply finger tip pressure for 10 seconds 4Rub the sternum with the knuckles - correct answer -1Squeeze the trapezius muscle firmly - A newborn has hyperbilirubinemia and is being treated with a biliblanket. Which intervention is indicated during this therapy?1Discontinue breastfeeding during treatment 2Rotate the neonate to treat all of his/her skin 3Restrict holding the newborn during treatment 4Provide more frequent feedings - correct answer -4Provide more frequent feedingsA client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts, "You think you're so perfect, pure and good." How should the nurse respond? 1"You seem to be in a bad mood." 2"Perfect? I don't quite understand." 3"You sound angry right now." 4"That explains why you've been staring at me." - correct answer -3 The client with coronary artery disease has a prescription for nitroglycerin transdermal patches. What is the best reason the client should not wear a patch for more than 12 to 14 hours each day? 1It can cause severe headaches 2It may no longer work as well 3It will cause profound hypotensive effects 4it will irritate the skin - correct answer -2 A hospitalized infant is receiving gentamicin. Which nursing intervention should receive priority in the plan of care? 1Compare daily infant weights 2Monitor the infant's urine output 3Ensure appropriate fluid intake 4Maintain accurate intake and output - correct answer -2 A newborn is diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize which point? 1They can expect the child will be mentally retarded 2Administration of a thyroid hormone will prevent problems 3This rare condition is hereditary 4Physical growth and development will be delayed - correct answer -2A child is admitted to the hospital for emergency surgery. The child's parent reports several allergies. Which of these allergies should all the operative health care personnel be notified about? 1Perfumed soap 2Shellfish 3Balloons 4Mold - correct answer -3 A practical nurse (PN) team member identifies that the fundus is boggy for a woman who is gravida 4 para 4 and is two hours after a spontaneous vaginal delivery. The fundus is displaced slightly above and to the right of the umbilicus. What should be the initial nursing action? 1Assist the woman to empty her bladder 2Monitor the pulse and blood pressure 3Call the registered nurse (RN) immediately 4Check lochia for color and amount - correct answer -1Assist the woman to empty her bladder - The nurse is planning the therapeutic milieu and the various activity groups for a client. What is the primary goal for the nurse to consider? 1Diminish destructive behavior through peer pressure 2Plan strict schedules with defined expectations 3Punish inappropriate behavior as it occurs 4Achieve a client's therapeutic goals - correct answer -4Achieve a client's therapeutic goals - A client tells a nurse, "I have something very important to tell you if you promise not to tell anyone." Which statement by the nurse would be the most appropriate response? 1"That depends on what you tell me." 2"I must report everything to the treatment team." 3"All right, I promise." 4"I can't make such a promise." - correct answer -4"I can't make such a promise." - A client is discharged with a prescription for warfarin. A nurse recognizes that additional teaching is needed if the client makes which incorrect comment? 1"I know I must avoid crowds." 2"I will report any bruises or bleeding." 3"I plan to use an electric razor for shaving." 4"I will keep all laboratory appointments." - correct answer -1"I know I must avoid crowds." - The nurse discovers an unresponsive client and determines there is no pulse. This nurse then activates the code notification button to alert all personnel about the code and begins chest compressions. What is the function of the second nurse on the scene? 1Validate the client's advance directive 2Participate with the compressions or breathing as requested by the first nurse 3Bring the code cart - 4Relieve the first nurse on the scene and continue single person CPR - correct answer -3 The nurse and client are discussing the client's progress toward understanding the client's behavioral responses to stressful events. This is typical of which phase in the therapeutic relationship? 1Termination 2Working - 3Orientation 4Pre-interaction - correct answer -2 The nurse is collecting data on a group of clients in a long-term health care facility. Which client is at a highest risk for the development of pressure ulcers? 1Ambulatory client who had three incontinent diarrhea stools in the past 24 hours 2Ambulatory older adult diagnosed with type 2 diabetes for the past 20 years 3Obese client who uses a wheelchair throughout the facility 4Malnourished older adult client who is on bed rest - correct answer -4 A client diagnosed with head trauma is in a non-responsive state. Vital signs are stable and breathing is regular and spontaneous. What should the nurse document to accurately describe the client's status? 1Glasgow Coma Scale 13, no ventilator required 2Glasgow Coma Scale 8, respirations regular - 3Appears to be sleeping, vital signs stable 4Comatose, breathing unlabored; is resting - correct answer -2A client with heart failure is newly referred to a home health care agency. The nurse determines that the client has not been following the prescribed diet. It would be most appropriate for the nurse to take which action at this time? 1Notify the health care provider of the client's failure to follow the prescribed diet 2Make a referral to Meal-on-Wheels for delivery of one meal three times a week 3Discuss the diet with the client to learn the reasons for not following the diet - 4Recommend a release from home health care related to noncompliance - correct answer -3 A client has chronic renal failure and is being treated at home. During weekly home visits, which factor is the most accurate indicator of fluid balance? 1Trends in daily weights - 2Skin turgor over at least two areas of the body 3Changes in mucous membrane moistness 4Difference between intake and output - correct answer -1Trends in daily weights - The client is receiving a thrombolytic agent to open a clot-occluded coronary artery following a myocardial infarction. Which finding would be the greatest concern and should be immediately reported to the registered nurse? 1Hematemesis - 2Pink-tinged saliva 3Serosanguinous drainage from the IV site 4Slight rust-colored urine - correct answer -1Hematemesis - The nurse is caring for a postoperative client following a closed reduction of distal tibia and midfemur fractures. The client has a long leg plaster cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 F (39.4 C). What should be the first action by the nurse? 1Check the distal circulation of the casted extremity 2Obtain the pulse oximetry reading 3Measure the client's blood pressure in the supine and Fowler's positions 4Check the orientation to time, place and person - correct answer -2The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the priority action by the nurse to accurately assess correct placement of the G-tube? 1Listen for active bowel sounds in all four quadrants 2Measure the pH of stomach content aspirate 3Auscultate the abdomen while instilling 10 mL of air into the G-tube 4Measure the length of tubing from the insertion site each shift - correct answer -1Listen for active bowel sounds in all four quadrants 2Measure the pH of stomach content aspirate - 3Auscultate the abdomen while instilling 10 mL of air int1Listen for active bowel sounds in all four quadrants 2Measure the pH of stomach content aspirate - 3Auscultate the abdomen while instilling 10 mL of air into the G-tube 4Measure the length of tubing from the insertion site each shifto the G-tube 4Measure the length of tubing from the insertion site each shift The client is diagnosed with infective endocarditis of the tricuspid valve. Which finding suggests a complication of this condition? 1Pronounced wheezes 2Pain on deep inspiration 3Sudden back pain 4Sudden dyspnea - correct answer -4 A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What should the nurse understand about the purpose of this procedure? 1The surgical repair of a diseased coronary artery 2An noninvasive radiographic examination of the heart 3A process to compress arterial plaque to improve blood flow 4The placement of an automatic internal cardiac defibrillator - correct answer -3 A 2 day-old infant born with spina bifida and meningomyocele is recovering after an initial surgery. As the nurse accompanies the grandparents for their first visit since the child's birth, which of these responses might the nurse expect from the grandparents? 1Anger2Disbelief 3Depression 4Frustration - correct answer -2 The ICU nurse works in a rural hospital that has a remote electronic ICU monitoring system (eICU.) What is one of the best reasons for having access to an eICU? 1An ICU nurse and intensivist remotely monitor ICU clients around the clock 2An ICU nurse is on-call to answer questions when needed 3Clients can ask the intensivist for a second opinion 4Less staff is needed on site when a remote eICU is available - correct answer -1 A child has severe burns to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse should care for this client with the knowledge that the most important reason for such a diet is to achieve which result? 1Provide a well-balanced nutritional intake 2Promote healing and strengthen the immune system 3Spare protein catabolism to meet metabolic and healing needs 4 stimulate increased peristalsis and nutrient absorption - correct answer -3 A nurse is reinforcing information about the administration of an albuterol inhaler to an adult diagnosed with asthma. What should be the priority comment made by the nurse? 1"Use this medication at bedtime to promote rest." 2"Notify the health care provider if your canister lasts only two weeks." 3"Inhale this medication after other asthma sprays." 4"Discontinue the inhaler if you are dizzy." - correct answer -2 An 80 year-old client is hospitalized for a chronic condition. The client informs family members that a living will has been prepared and the client wants no life-prolonging measures performed. The client's condition deteriorates and the client becomes unresponsive. Which of the following nursing actions is most appropriate? 1Notify the attending physician 2Consult the charge nurse and prepare to transfer the client to an intensive care unit 3Call the rapid response team4Contact the family member indicated in the admission forms - correct answer -1 The nurse is caring for a client who has just been admitted to the inpatient mental health unit with severe depression. Which concern should be a priority of care? 1Safety 2Elimination 3Rest 4Nutrition - correct answer -1 A nurse is discussing with a client the precautions with warfarin. The nurse should tell the client to avoid foods with excessive amounts of what substance? 1Iron 2Calcium 3Vitamin E 4Vitamin K - correct answer -4 The nurse has established a therapeutic relationship with a client. Which observation would indicate that the nurse-client relationship has passed from the orienting phase to the working phase? 1The client revitalizes a relationship with the family to help in coping with a child's death 2The client recognizes feelings and expresses them appropriately 3The client expresses a desire to be mothered and pampered 4The client recognizes regression as a part of a defense mechanism - correct answer -2 During the working phase, problems are identified and the client is able to focus on unpleasant feelings and express them appropriately. During the working phase, problems are identified and the client is able to focus on unpleasant feelings and express them appropriately. - correct answer -An advance health care directive is also known as a living will. It is a legal document in which a person specifies his or her wishes concerning medical treatments at the end-of-life, when s/he is unable to make those decisions. Advance care planning involves sharing personal values and wishes with loved ones and selecting someone, (called a medical power of attorney or health care proxy) who will eventually make medical decisions on the client's behalf A nurse is talking to a group of parents about how to reduce risks in the home. What is the most important factor for the nurse to consider during the discussion?1Proximity to emergency services 2Number of children in the home 3Knowledge level of the parents 4Age of children in the home - correct answer -4 When reviewing the medication lithium with a client, the client asks, "How long will it take before I can feel the effects of the medication?" Which response by the nurse is the best? 1"About two weeks" 2"One month" 3"Immediately" 4"Several days" - correct answer -1 A client has completed a renal biopsy. Which nursing intervention is appropriate after a renal biopsy? 1Ambulate the client within four hours after procedure 2Change the dressing when it becomes saturated 3Monitor vital signs using post-op protocols 4Maintain client on NPO status for 24 hours - correct answer -3 The nurse is caring for a client who is one-day postoperative with a T-tube following a cholecystectomy. What color would the nurse expect the drainage from the client's T-tube to be? 1Dark brown 2Green 3Yellowish-brown 4Orange - correct answer -3 A newly admitted client reports taking phenytoin for several months. Which of the following assessments should the nurse be sure to include in the admission report? (Select all that apply.) - correct answer -Serious adverse outcomes of antiseizure medications such as phenytoin (Dilantin) are unsteady gait, slurred speech, extreme fatigue, blurred vision or feelings of suicide. Increased hunger (not anorexia), increased thirst or increased urination are additional serious side effects. The nurse is giving a morning bath to a client who has a colostomy. While giving the bath, the nurse should reinforce that the collection pouch should be emptied at what time?1Prior to going to sleep at night 2After each fecal elimination 3At the same time each day 4When it is one-third to one-half full - correct answer -4 A client is scheduled to have blood drawn for serum cholesterol and triglycerides tomorrow morning. What information should the nurse reinforce to the client about the test? 1"Be sure to eat a fat-free diet until the test, and drink lots of water." 2"Stay at the laboratory so that two blood samples can be drawn an hour apart." 3"Do not eat or drink anything but water for 12 hours before the blood test." 4"Have the blood drawn within two hours of eating breakfast." - correct answer -3 The nurse is caring for a hospitalized adolescent. The nurse recognizes that which of these concerns will be the greatest for a hospitalized adolescent? 1Restricted physical activity 2Separation from family 3Altered body image 4Unrelieved pain - correct answer -3 In checking a postpartum client, the nurse palpates a firm fundus. However, the nurse also observes a constant trickle of bright red blood from the vaginal opening. What should the nurse suspect? 1Retained placenta 2Clotting disorder 3Vaginal lacerations 4Uterine atony - correct answer -3 A client diagnosed with gout is admitted with severe pain, swelling and redness in the proximal toe joint of the right foot. The nurse should anticipate that the plan of care would include which focus? 1High-protein diet 2Fluid intake of at least 3000 mL/day 3Acetaminophen for inflammation 4Hot compresses to affected joints - correct answer -2A 6 year-old child is hospitalized with findings of moderate edema, gross hematuria and mild hypertension associated with the diagnosis of acute glomerulonephritis (AGN). Which nursing intervention would be appropriate for this client? 1Weigh the child twice per shift 2Relieve boredom through physical activity 3Institute seizure precautions 4Encourage the child to eat protein-rich foods - correct answer -3 A mother asks about expected motor skills for her 3 year-old child. Which activity should the nurse discuss as normal at this age? 1Riding a tricycle 2Tying shoelaces 3Jumping rope 4Playing hopscotch - correct answer -1 The nurse is assessing a client who has been treated long-term with glucocorticoid therapy. Which finding might the nurse expect? 1Jaundice 2Peripheral edema 3Buffalo hump 4Increased muscle mass - correct answer -3 A client diagnosed with autism begins to eat with both hands. The nurse can best handle the behavior by using which approach? 1Commenting "I believe you know better than to eat with your hands." 2Removing the food and stating "You can't have any more food until you use the spoon." 3Jokingly stating "Well, I guess fingers sometimes work better than spoons." 4Placing the spoon in the client's hand and stating "Use the spoon to eat your food." - correct answer -4 The client is diagnosed with heart failure and oral digoxin is prescribed. What is the priority nursing assessment for this medication?1Monitor serum electrolytes and creatinine 2Measure apical pulse prior to administration 3Maintain accurate intake and output ratios 4Monitor blood pressure every 4 hours - correct answer -2 A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What should be the next action of the nurse? 1Arrange to change client-care assignments 2Discuss with the parent the appropriate use of "time-out" 3Explain to the mother that the child needs extra attention 4Explain to the parent that this behavior is expected - correct answer -4 The mother of a hospitalized 2 year-old child asks a nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The best advice by the nurse would include which approach? 1Explain that this behavior will stop with in a few days 2Suggest that the mother "sneak out" of the child's room when the child is asleep 3Request for the mother to remain with the child at all times 4Help the mother understand that this is a normal response to hospitalization - correct answer -4 A client has a percutaneous endoscopic gastrostomy (PEG) tube that is used to administer feedings and medications. Which nursing action is best to ensure patency of the tube? 1Encouraging the client to cough to relieve abdominal bloating prior to or following a feeding 2Adequately flushing the tube with water before and after use 3Completely crushing all medications prior to administration 4Squeezing the tube to dislodge obstructions - correct answer -2 A nurse is observing an 8 month-old client. Which behavior would the nurse anticipate the infant to be able to display? 1Pull up to stand 2Use a spoon 3Say two words4Sit without support - correct answer -4 A client is admitted with newly diagnosed hypothyroidism. A nurse would expect the client to exhibit which finding until the client achieves a euthyroid state with therapy? 1Heat intolerance 2Diarrhea 3Tachycardia 4Lethargy - correct answer -4 The licensed practical nurse is caring for a client with advanced cirrhosis of the liver. Which finding should receive immediate follow-up by the charge nurse? 1Jaundice 2Anorexia 3Hematemesis 4Ascites - correct answer -3 A nurse discusses the healthy use of both conscious and unconscious defense mechanisms with a group of clients. An appropriate goal for these clients would be to use these mechanisms for which purpose? 1Foster independence with better communication 2Protect the ego and diminish anxiety 3Eliminate anxiety and apprehension 4Avoid conflict and unpleasant consequences - correct answer -2 A 3 year-old child is brought to the health clinic. The grandmother reports that the child is always "scratching his bottom" and is "extremely irritable." Based on this information, which health issue would the nurse assess for initially? 1Pinworm 2Scabies 3Ringworm 4Allergies - correct answer -1The nurse is caring for a client diagnosed with acute angina. The client reports substernal chest pain, diaphoresis and nausea. What should be the first action by the nurse? 1Administer PRN pain medication as ordered 2Determine the origin of the pain 3Draw blood for for troponin/CK and CBC per standing orders 4Order ECG per standing orders - correct answer -1 The client is diagnosed with Parkinson's disease (PD) and takes more than one hour to dress for scheduled therapies. Based on this finding, what is the most appropriate nursing intervention? 1Allow the client the time needed to dress 2Encourage the client to dress more quickly 3Ask family members to dress the client 4Demonstrate methods on how to dress more quickly - correct answer -1 A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse's explanation should include which of these comments? 1"It tells us how far along your pregnancy is." 2"It can help identify potential neurological defects." 3"The results help determine if the baby is growing normally." 4"The placental exchange of oxygen is measured." - correct answer -2 A client is diagnosed with a severe mental illness. What is the priority goal of involuntary hospitalization? 1Protection from harm to self and others 2Return to independent functioning 3Elimination of negative findings 4Reorientation to reality - correct answer -1 A pregnant woman in the third trimester reports having severe heartburn. What action should a nurse remind the client to take? 1Drink small amounts of liquids frequently 2Eat the evening meal within two hours of going to sleep 3Sleep with head propped on several pillows4Take a proton pump inhibitor either before or after eating - correct answer -3 A practical nurse (PN) is observing an 8 month-old infant in the clinic waiting room. Which activity should be reported to the registered nurse (RN)? 1Lifts head from the prone position 2Rolls from abdomen to back 3Falls forward when sitting 4Responds to parents' voices - correct answer -3 A nurse is monitoring the client's initial postoperative condition after a total thyroidectomy. Which findings should the nurse expect as complications and report immediately to the registered nurse (RN)? 1Paresthesia and muscle cramping 2Mild dysphagia and hoarseness 3Headache and nausea 4Irritability and insomnia - correct answer -1 An 18 year-old client is admitted to intensive care from the emergency department after a diving accident. The injury to the spinal cord is suspected to be at the level of the second cervical vertebrae (C-2). When collecting data, which issue should be the priority focus? 1Muscle weakness 2Respiratory function 3Bladder control 4Peripheral sensation - correct answer -2 There's a new order to apply one-inch of nitroglycerin paste to the client's chest every 12 hours, but the medication is not in the automatic medication dispensing system's drawer for this client. What should the nurse do next? 1Use another client's nitroglycerin paste until pharmacy sends a tube for this client 2Substitute an equivalent amount of nitroglycerin sublingual spray from the crash cart 3Call the pharmacy to send up a tube of nitroglycerin paste 4Call the prescriber and ask to substitute a different formulation of nitroglycerin - correct answer -3A nurse is caring for a child being discharged after a tonsillectomy. Which instruction is appropriate for the nurse to reinforce with the parents? 1Report a persistent cough to the health care provider 2The child can return to school in four days 3Administer chewable medication for pain 4The child may gargle as necessary for discomfort - correct answer -1 An 80 year-old client is scheduled for a cardioversion. The nurse is reviewing the client's medication administration records for the previous 24 hours. Which medication would prompt the nurse to notify the health care provider? 1Diltiazem (Cardizem) 2Digoxin (Lanoxin) 3Nitroglycerine ointment 4Metoprolol tartrate (Toprol XL) - correct answer -2 A nurse has reinforced teaching for a client who is being discharged after an arterial revascularization of the right lower extremity. Which statement made by the client is incorrect and requires further discussion with the nurse? 1"Smoking will decrease the circulation to my leg" 2"Coughing and deep breathing are important for a few weeks." 3"I will put my right leg through a full range of motion." 4"I might feel a throbbing pain in my right leg." - correct answer -3 The nurse is assisting in the application of a plaster cast for a client with a broken arm. Which action is a priority? 1The cast material should be dipped several times into warm water 2The cast should be uncovered until it dries 3The casted extremity should be placed on a supporting surface 4The wet cast should be handled with the palms of hands for 48 to 72 hours - correct answer -4 The client undergoes a gastrectomy. Several hours after surgery, the nasogastric (NG) tube stops draining. What action does the LPN anticipate the RN will take first? 1Reposition the tube2Increase the amount of suction 3Gently irrigate the tube with sterile normal saline 4Notify the surgeon - correct answer -3 A 12 year-old child, admitted with a broken arm, is waiting for a scheduled surgery. The nurse finds the child crying and unwilling to talk. What would be the most appropriate initial response by the nurse? 1Reassure the child that the surgery will go fine with no problems 2Provide privacy with encouragement to work through feelings 3Distract the child with a choice of activities to do while waiting for surgery 4Make arrangements for friends to visit as soon as possible - correct answer -2 A nurse is caring for a client with a sigmoid colostomy. The client requests assistance in removing the flatus from a one-piece drainable ostomy pouch. Which intervention should the nurse use? 1Pierce the plastic at the top of the ostomy pouch with a pin to vent the flatus 2Pull the adhesive seal around the ostomy pouch to allow the flatus to escape 3Open the bottom of the pouch to allow the flatus to be expelled 4Assist the client to ambulate to reduce the flatus in the pouch - correct answer -3 A client returns from the operating room after a right orchiectomy. What is the priority nursing intervention during the immediate postoperative period? 1Manage postoperative pain 2Maintain fluid and electrolyte balance 3Control bladder spasms with PRN medication 4Ambulate the client within a few hours after surgery - correct answer -1 The nurse enters the room of a postpartum mother and observes the baby lying at the edge of the bed while the mother sits in a chair. The mother states, "This is not my baby, and I do not want it." How should the nurse respond? 1"What a beautiful baby! The baby's eyes are just like yours." 2"This is a common occurrence after birth. Let's talk about how to accept the baby." 3"You seem upset, tell me about how you are feeling"? 4"Many women have postpartum blues and need some time to love the baby." - correct answer -3The client calls the clinic nurse and reports nausea, headache and fatigue. The client also reports seeing yellow halos around lights. What is the best response by the nurse? 1"Do your eyes appear bloodshot and is there any itching?" 2"Tell me about your prescription for digoxin. Are you still taking the medication?" 3"Call back in a week and schedule an appointment if your symptoms don't improve." 4"Is there anyone else at home who has the same symptoms?" - correct answer -2 A client is admitted to the mental health inpatient unit with a diagnosis of major depression after a suicide attempt. In addition to expressions of sadness and hopelessness, the nurse anticipates observing which characteristics? 1Meticulous attention to hygiene, grooming 2Anxiety, hostility 3Psychomotor retardation, agitation 4Guilt, indecisiveness - correct answer -3 A nurse is assigned to care for a 10 month-old infant with the new diagnosis of anemia. Which of these findings should the nurse anticipate? 1Behavior consistent with hyperactivity 2Slow heart rate when sleeping 3Pale mucosa inside the mouth 4High hemoglobin level - correct answer -3 The nurse is assisting a withdrawn client to begin to develop relationship skills. Which nursing intervention should be most effective? 1Assist the client to analyze the meaning of behaviors 2Remind the client frequently to interact with other clients 3Offer the client frequent opportunities to interact with the nurse 4Initiate client interactions with one or two other clients - correct answer -3 A female client admitted for a breast biopsy says tearfully to a nurse, "If this turns out to be cancer and I have to have my breast removed, my partner will never come near me." What would be the most appropriate response to this statement?1"Are you questioning the depth of your relationship?" 2"Why are you concerned that you will be rejected?" 3"You sound worried that the surgery might change your relationship with your partner." 4"I'm sure your companion will understand." - correct answer -3 The client is diagnosed with asthma. What information should the nurse reinforce that the client should monitor on a daily basis? 1Peak air flow volume 2Respiratory rate 3Pulse oximetry 4Skin color - correct answer -1 The client underwent a total hip arthroplasty 48 hours ago. The client has been up in a chair and is prescribed physical therapy twice daily. What type of nursing care is needed for this client? (Select all that apply.) - correct answer -Two days after surgery, the client will be walking in the hallway. When in bed, the client should continue to perform leg exercises and use a pillow or foam wedge between his or her legs (to keep the legs abducted.) The drain is usually removed the second day after surgery; there should be little-to-no drainage on the second post-op day. A nurse is providing home care for a client diagnosed with chronic heart failure and episodes of pulmonary edema. Which nursing diagnosis should the nurse expect as a priority in the plan of care? 1Activity intolerance related to an imbalance of oxygen supply and demand 2Imbalanced nutrition related to poor appetite 3Risk for impaired skin integrity related to dependent edema 4Constipation related to reduced activity level - correct answer -1 The nurse has been reinforcing information about cardiac risks to adult clients when they visit the hypertension clinic. What would be the best way to determine if learning has occurred? 1Performance on written tests 2Completion of a mailed survey 3Responses to verbal questions 4Reported behavioral changes - correct answer -4The client undergoes a laparoscopic removal of the appendix. Which postoperative instructions will the nurse reinforce? (Select all that apply.) - correct answer -may cause shoulder discomfort postoperatively. Clients should keep the dressings clean and dry for 48 hours before they can shower, but no tub baths for a few weeks. If "skin glue" is used over the incision(s), the client should not try to scrub it off because it will wear off on its own. Clients may resume normal activities as soon as they are able but no heavy lifting or aerobic exercise for about 2 weeks. If they do not have a BM after 2-3 days, clients can take 2 tablespoons of MOM several times a day until they have a BM. Diet can be advanced as tolerated but it's best to stick to non-greasy, non-spicy foods for a few days. The nurse is caring for a postoperative client. What is the priority nursing intervention the nurse will reinforce for preventing atelectasis? 1Turn, cough and breathe deeply 2Ambulate client within 12 hours 3Maintain adequate hydration 4Splint incision when moving or coughing - correct answer -1 A nurse is working with parents to plan home care for a toddler with a heart problem. What should be the priority nursing intervention on the plan of care? 1Assist the parents to plan quiet play activities with the toddler at home 2Stress to the parents that they will need relief care givers 3Instruct the parents for them and the toddler to avoid contact with persons with infection 4Encourage the parents to enroll in child cardiopulmonary resuscitation (CPR) class - correct answer -4 A client becomes acutely short of breath with an SpO2 (oxygen saturation) of 82%. Which oxygen delivery system should the nurse apply that would provide the highest concentrations of oxygen to the client? 1Simple face mask 2Partial rebreather mask 3Venturi mask 4Non-rebreather mask - correct answer -4 A nurse gathers data related to delayed gross motor development in a 3 year-old client. Which observation by the nurse should confirm this finding? 1Cannot ride a bicycle 2Cannot catch a ball3Cannot skip on alternate feet 4Cannot stand on one foot - correct answer -4 A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes lost when outside of the home. Which statement would provide the best reality orientation for this client? 1"Hello. My name is Elaine Jones and I am your nurse for today." 2"Good morning. You're in the hospital. I am your nurse Elaine Jones." 3"How are you today? Remember, you're in the hospital. I will be your nurse all day. My name is Elaine Jones." 4"Good morning. I am Elaine Jones, your nurse. Do you remember where you are?" - correct answer -2 A client is diagnosed with a Salmonella infection. What is a primary nursing intervention to be taken to minimize the transmission of disease from this client? 1Double glove when in contact with feces or emesis 2Wash hands thoroughly before and after any client contact 3Wear gloves when disposing of contaminated linens 4Use gloves when in contact with body secretions - correct answer -2 A 6 month-old infant is being treated for developmental hip dysplasia and has been placed in a hip spica plaster cast. Which discharge information is important for the nurse to reinforce with the parents? 1Turn the baby every two hours using the abduction stabilizer bar 2Check frequently for swelling in the baby's feet 3Gently rub the skin with a cotton swab to relieve itching 4Place favorite books and push-pull toys in the crib - correct answer -2 A nurse is talking to parents about the side effects of routine immunizations. Which finding should the nurse reinforce about calling the health care provider if it occurs within 24 to 48 hours after a routine immunization? 1Localized tenderness at the injection site 2Tympanic temperature of 104 F (40 C) 3Some irritability and fussiness4Swelling at the injection site - correct answer -2 A 28-year-old is transferred to the emergency department (ED) via ambulance with a traumatic head injury. The client is awake and reports having a headache and some amnesia. What are the priority nursing interventions for this client? (Select all that apply.) - correct answer -Correct Response Assess vital signs and neurological function Assess the airway Prepare for CT imaging of the head Assess the wound for presence of drainage or bruising on the head A client exhibits many delusional thoughts. As the nurse assists the client to prepare for breakfast, the client comments, "Don't waste good food on me. I'm dying from this disease I have." Which response by the nurse would be the best? 1"None of the laboratory reports show that you have any physical disease." 2"Try to eat a little bit. Breakfast is the most important meal of the day." 3"I know you believe that you have an incurable disease." 4"What has your primary health care provider told you?" - correct answer -3 The family member tells an admitting nurse that the client values the practice of Chinese medicine. The nurse must understand that for this family and client a priority goal should take which focus? 1Achieve harmony 2Respect life in old age 3Maintain energy balance 4Restore yin and yang - correct answer -4 The nurse is reinforcing dietary instructions to the parents of a child diagnosed with cystic fibrosis. The nurse will emphasize which of the following characteristics of this diet? 1A gluten-free diet, avoiding foods that contain wheat, rye and barley 2Balanced, high calorie diet with extra fat, salt, protein and calcium 3Foods low in sodium, potassium and phosphorus 4Carbohydrate counting, selecting foods from the bread/starch, fruit, or milk group - correct answer -2The nurse works in a psychiatric inpatient setting. What information should the nurse be aware of as one of the most frequent reasons for suicide in adolescents? 1Progressive failure to adapt to peer pressure 2Reunion wish or a fantasy of some sort 3Feelings of anger or hostility toward others 4Feelings of alienation or isolation from peers - correct answer -4 When a client returns from surgery after an open reduction with cast application for a femur fracture, a small blood stain is noted on the cast by the nurse. Four hours later, the nurse observes that the stain has doubled in size. What is the initial action for the nurse to take at this time? 1Ask the family members to call you when they notice the spot getting larger 2Record the findings in the nurse's notes 3Outline the spot with a pen and note the time and date on the cast 4Report the finding to the registered nurse (RN) charge nurse - correct answer -3 The nurse is discussing an illness with a 10 year-old child. What should the nurse keep in mind about this child's ability to understand the information at this stage of development? 1Makes simple association of ideas 2Bases conclusions on abstract thinking I3nterprets events from own perspective 4Thinks logically to organize facts - correct answer -4 The nurse calls for help after finding an unresponsive adult client in a hospital room. What action should the nurse take next for the client who has no pulse and is not breathing? 1Open the airway and deliver two breaths followed by 30 compressions 2Provide continuous chest compressions until someone comes with the crash cart 3Provide a cycle of 30 compressions followed by two breaths 4Provide 15 compressions and then pause while someone delivers one "breath" using an ambu bag - correct answer -3 A nurse is discussing with a group of parents when they can begin teaching their preschool children about injury prevention. Which approach should the nurse reinforce? 1Discuss the consequences of not wearing protective devices2Protect their preschooler from outside influences 3Set good examples themselves through their actions 4Make sure their preschooler understands all the safety rules - correct answer -3 The nurse is caring for a postmature infant in the newborn nursery. What factor should the nurse recognize as being the primary reason associated with complications of being post-term? 1Depletion of subcutaneous fat 2Progressive placental insufficiency 3Excessive fetal weight 4Low blood sugar levels - correct answer -2 The registered nurse (RN) has initiated the administration of an intravenous vesicant chemotherapeutic agent to a client. Which finding during the care by a practical nurse (PN) would require the PN to immediately notify the RN? 1A rash on the client's extremities 2Complaints of pain at the infusion site 3Stomatitis lesions in the mouth 4Severe nausea and vomiting - correct answer -2 A client with testicular cancer has had a unilateral orchiectomy. Prior to discharge the client expresses his fears related to the prognosis. Which statement should be the initial response by a nurse? 1"Self-examination needs to be continued in order to prevent and detect recurrences." 2"Chemotherapy is most likely to be started right away." 3"Adoption may be a consideration if you want children." 4"Testicular cancer has a very high cure rate with early diagnosis and treatment." - correct answer -4 A nurse is caring for a child who has been recently diagnosed with cystic fibrosis. Which finding should the nurse anticipate? 1Dry, nonproductive cough 2Poor appetite 3Frequent urinary infections 4Ribbon-like stools - correct answer -1The nurse is caring for a client who is diagnosed with chronic renal failure with hemodialysis three times per week. The client becomes confused and irritable six hours before the next treatment. Which of these findings might explain the reason for the client's behavior? 1Low potassium level 2Elevated blood urea nitrogen (BUN) 3Low calcium level 4Metabolic alkalosis - correct answer -2 The client is instructed to collect stool specimens at home using the guaiac test. In addition to explaining how to collect the specimens, the nurse instructs the client to avoid certain substances prior to obtaining the stool specimens. Which of the following substances should the client avoid? (Select all that apply.) - correct answer -a false positive test and should be avoided for at least 3 days before the fecal occult blood test; Fruits and vegetables with high peroxidase activity, such as red radishes, broccoli, and cauliflower should also be avoided several days prior to obtaining specimens. Clients should also limit their intake of vitamin C because too much can lead to a false negative result. A client with a fracture of the radius had a plaster cast applied two days ago. The client calls the clinic to report constant pain and swelling of the fingers since the cast was applied. What should be the next action of a nurse? 1Suggest to elevate the arm higher than heart level 2Ask if numbness is present in the fingers and if the client can move the fingers 3Have the client make an appointment with the surgeon for the next day 4Approve the application of a cool cloth to the fingers of the affected arm - correct answer -2 The client is seen in the emergency one day after falling in his bathroom at home. The client reports having "a few drinks" prior to the fall. Which finding requires the nurse's immediate attention? 1Bruise behind one ear 2Blurred vision 3Nausea and vomiting 4Headache - correct answer -1 Diagnosed with heart failure, the client had an implantable cardioverter-defibrillator (ICD) implanted several years ago. The client now has end-stage heart failure and is receiving home hospice care. Which end-of-life care option could have the greatest impact on client comfort?1Encouraging the client to sit upright in bed 2Confirming advanced directives and plans for resuscitation 3Deactivating the implantable cardioverter-defibrillator (ICD) 4Assisting the client to eat several small meals - correct answer -3 The client is prescribed alendronate (Fosamax). What information about medication administration should the nurse be sure to reinforce? 1Take on an empty stomach 2Take with milk, two hours after meals 3Take with calcium 4Take after meals - correct answer -1 A couple experienced a miscarriage at seven months of pregnancy. The nurse makes a home visit one week after discharge from the hospital. What intervention should the nurse emphasize to the couple during the home visit? 1Plan another pregnancy as soon as possible 2Seek causes of the death for prevention purposes 3Focus on the other healthy children at home 4Discuss feelings with support persons and each other - correct answer -4 A nurse is reinforcing information to a mother who is breast-feeding a newborn infant diagnosed with oral candidiasis. Which statement by the mother would be incorrect and indicate a need for reinforcement of information? 1"The therapy can be discontinued when the spots disappear." 2"I will boil the nipples and pacifiers for 20 minutes." 3"Expressed breast milk should be used immediately or frozen." 4"Nystatin should be given four times a day after my baby eats." - correct answer -1 The nurse is to administer meperidine 100 mg, atropine 0.4 mg, and promethazine 50 mg IM to a client preoperatively. Which action should the nurse take initially? 1Place the bed in the low position 2Instruct the client to remain in bed 3Place the call bell within reach4Have the client empty the bladder - correct answer -4 The parents of a school-age child are providing information to the nurse about their child. Which of these health issues should the nurse recognize as a finding that could suggest type 1 diabetes? 1Being a picky eater 2Weight gain 3Bedwetting 4Oily and acne-prone skin - correct answer -3 An adolescent client arrives at a clinic three weeks after the birth of her first baby. She tells the nurse she is very worried about not returning to her pre-pregnancy weight. Which approach should the nurse take first? 1Review the client's pattern of weight gain over the past year 2Encourage her to talk about her self-image 3Give her several pamphlets on postpartum nutrition 4Ask the mother to record her diet for the next few weeks - correct answer -2 A nurse is caring for a client admitted with the diagnosis of suspected Legionnaire's disease. Which finding would require the nurse's immediate attention? 1Dry mouth with frequent requests for water 2Abdominal gas pains that are severe and disappear suddenly 3 Increased use of accessory muscles of breathing 4Difficulty sleeping due to leg cramps - correct answer -3 Legionnaire's disease is a type of acute bacterial pneumonia. Increased use of accessory breathing muscles and labored breathing are indicators of respiratory distress and should be reported immediately. The nurse is caring for a client with congestive heart failure. Which task can the nurse delegate to the unlicensed assistive person (UAP)? 1Record and report the client's intake and output. 2Inspect and report peripheral IV site status. 3Palpate for edema in the lower extremities. 4Evaluate understanding of prescribed medications. - correct answer -1A client refuses to take the medication prescribed because the client prefers to take an herbal preparation instead. What is the first action the nurse should take? 1Discuss with the client to find out about the preferred herbal preparation 2Explain the importance of the medication to the client 3Contact the client's health care provider about the refusal 4Report the behavior to the charge nurse - correct answer -1 The nurse is caring for a group of clients when a fire alarm sounds in the hospital cafeteria. What should the nurse do next? 1Close all doors in the area. 2Find the fire extinguisher. 3Remove oxygen devices. 4Begin evacuating the clients. - correct answer -1 The licensed practical nurse (LPN) is caring for a client with an order that reads, "morphine sulfate 2 mg IV push every 3 to 4 hours as needed for pain." There are no other licensed persons working that shift. Which action should the nurse take? 1Give the medication orally and follow-up with the health care provider. 2Hold the medication and contact the health care provider. 3Administer the prescribed dose as ordered. 4Check with the pharmacist to verify the order. - correct answer -2 The nurse is providing care for a client who was recently diagnosed with end-stage heart failure. The client does not have advance directives in place. Which of the following statements by the nurse would be appropriate? (Select all that apply.) - correct answer -"Have you thought about what you want done as your disease progresses?" "What does your family know about your condition and prognosis?" "Have you discussed your wishes regarding resuscitation with your health care provider?" A newly licensed nurse is concerned about time management. Which action should be most effective in the initial development of a time management plan? 1Set daily goals with the establishment of priorities 2Complete each task before beginning another activity3Ask for additional assistance when necessary to complete tasks 4Keep a time log for what was done during the hours worked - correct answer -4 A home health nurse is providing care for a client. Which client statement should the nurse report immediately to the client's health care provider? 1"When I emptied my urine catheter drainage bag it looked like rusty-colored water." 2"I just didn't sleep well the last few nights. I keep having sad thoughts running through my mind." 3"I really don't want home-delivered meals any longer. I am just not hungry." 4"My neighbors just don't visit me anymore since I came home from the hospital." - correct answer - 1 The LPN/VN assists the RN in evaluating the plan of care for clients. What action does the LPN focus on during the evaluation phase? 1Selection of interventions that are measurable and achievable 2Achievement or status of progress related to prior goals 3Identification of any findings of physical and psychosocial stressors 4Establishment of goals to ensure continuity of care - correct answer -2 A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law? 1Clinical specialty certification by an accredited organization 2Complete and accurate documentation of assessments and interventions 3Sworn statement that health care provider orders were followed 4Above-average performance reviews prepared by nurse manager - correct answer -2 The nurse is assigned to care for several clients on the day shift. Which client should the nurse see first after receiving shift report? 1The client with asthma who is scheduled for a chest X-ray prior to discharge 2The client with peptic ulcer disease who has been vomiting most of the night 3The client with chronic kidney disease who completed peritoneal dialysis two hours ago 4The client with pancreatitis who reports pain at a level of eight out of 10 - correct answer -2The nurse hears a health care provider (HCP) loudly criticizing one of the unlicensed assistive persons (UAP) within the earshot of others. The UAP does not react or respond to the HCP's complaints. What is the best action by the nurse? 1Notify the chief of the medical staff about the HCP's breach of professional conduct. 2Encourage the UAP to directly confront the HCP about the unprofessional behavior. 3Complete an incident report describing the HCP's unprofessional behavior. 4Walk up to the HCP and quietly state, "This unacceptable behavior has to stop." - correct answer -2 Information about case management and the role of the case management nurse is presented during an orientation session for new nurses. Which statement correctly describes an important fact about case management? 1Case management strategies focus mainly on the client's needs after discharge. 2Case management is a collaborative process designed to meet complex client needs. 3Physicians are responsible and accountable for client outcomes. 4The interdisciplinary team makes all the decisions for the client and family. - correct answer -2 During the management of a client's pain, the nurse should adhere to the code of ethics for nurses. Which of these actions should the nurse consider first when treating the client's pain? 1Cultural sensitivity is fundamental to client-centered pain management. 2Clients have the right to have their pain managed promptly. 3Nurses should not judge a client's pain based on the nurse's values. 4The client's self-report of pain is the most important consideration. - correct answer -4 A client with a musculoskeletal disorder has been newly fitted with a lower limb orthotic. Which activity can the nurse delegate to the certified nursing assistant (CNA)? 1Provide instruction to the client for ambulation with the orthotic. 2Monitor the client's response to moving with the orthotic. 3Check the client's skin for any redness or irritation from the orthotic. 4Assist with transferring the client from