2. first stage of labor whose contractions
are occurring every 30 seconds
The charge nurse has received a Contractions should be no longer than
change-of-shift report on the following 90 secs and no closer than 2 mins (120
clients in labor. The charge nurse should secs)
ask a staff member to first see the client 90 secs is the duration, 2 mins is the
in the frequency.
1. first stage of labor who has an oral
temperature of 99.7° F (37.6° C) Rationale:
2. first stage of labor whose contractions 1. Elevated temp is normal during labor
are occurring every 30 seconds 3. Increased resps are normal during
3. second stage of labor who has respi- labor "pant-pant-blow" "hee-hee-hoo"
rations of 26 breathing pattern
4. second stage of labor whose contrac- 4. Contractions shouldn't be longer than
tions are lasting for 60 seconds 90 secs, 60 secs is okay and normal
Second stage: 2-3 mins apart, 60-90
secs long, 10 cm dilated, strong pain
The nurse is observing a staff member
2. placing a box of disposable face
caring for a client who has chickenpox.
shields outside the client's room
Which of the following actions by the
disposable face masks are not suitable
staff member would require the nurse to
for airborne precautions
intervene?
1. placing the client in a private room with
Rationale:
monitored negative air pressure
Varicella (chickenpox) is airborne pre-
2. placing a box of disposable face
caution. Private, negative pressure room,
shields outside the client's room
universal precautions (hand sanitizer in
3. placing an alcohol-based hand rub in
room) and placing surgical mask on
the client's room for hand hygiene
client during transport are all correct in-
4. placing a surgical mask on the client
terventions for Varicilla.
during transport out of the client's room
The nurse is caring for a client who re- 2. transcutaneous pacing
ports feeling faint and is experiencing the - external pacing that stimulates the ven-
cardiac rhythm shown in the electrocar- tricles to pump at a set rate
diogram (ECG) strip below. 5. Assess the client for angina
- BRADYCARDIA (it is more than 5 - Angina (Chest pain) can be caused
spaces apart, sinus rhythm) by both tachycardia (most common) and
Which of the following actions would be bradycardia (rare but can happen). As-
appropriate for the nurse to take? Select sessment of angina is appropriate
,all that apply:
Rationale:
1. Administer the client's prescribed beta
1. Beta blocker would further decrease
blocker.
HR
2. Prepare for transcutaneous pacing.
3. Valsalva maneuver/Vagal stimulation
3. Instruct the client to perform the Val-
would further decrease HR. (can be in-
salva maneuver.
dicated for sinus Tachy)
4. Begin chest compressions.
4. Chest compressions are for cardiac
5. Assess the client for angina.
arrest
1. Encourage the client to reminisce
about happy memories.
The nurse is planning care for a client
Its possible for AD patients to retain
with moderate Alzheimer's disease (AD).
long-term memories
Which of the following interventions
should the nurse include in the client's
Rationale:
plan of care?
2. Acknowledge feelings --> Redirect is
1. Encourage the client to reminisce
protocol for Dementia. Don't confront;
about happy memories.
they can't learn
2. Confront the client when inappropriate
3. AD is irreversible
or agitated behaviors occur.
4. In moderate AD, dementia has already
3. Administer to the client the
progressed to where pt needs help with
cholinesterase inhibitor to reverse the
ADLs and planning daily activities. Ask-
course of AD.
ing them to plan can frustrate them and
4. Provide the client with information
cause distress.
about activity choices in the morning so
STRUCTURED pleasant activities that
the client can make plans for the day.
consider the persons likes and interests
are the best.
The nurse is teaching a client how to 1. "Use your hands and arms to support
ambulate using crutches. Which of the your body weight."
following information should the nurse True! But watch out if it isn't 2-3 fin-
include? ger-widths, crutch paralysis can occur.
1. "Use your hands and arms to support s/s: paresis and paresthesias in wrists
your body weight." and hands
2. "Wear slippers when ambulating with
the crutches in your home." Rationales:
3. "Maintain the crutches 12 in (30 cm) in 2. Fall risk!
front of your feet while standing." 3. Should be 6 in. in front and 6 in. lateral
,4. "Adjust the hand grips of the crutches 4. Elbows should be bent at 30 degree
so that your elbows are fully extended." angle
4. "I should expect the blurred vision to
resolve after I have received medications
for several weeks."
The nurse has taught a client with multi-
MS causes nerve damage and can re-
ple sclerosis (MS).
sult in optic neuritis (vision loss, burry
Which of the following statements by the
vision). In most cases it resolves itself
client would indicate a correct under-
in 4-12 weeks, but medication (steroids)
standing of the teaching?
can speed up the process and resolve it
1. "I will complete all of my household
quicker
chores in the morning when I am well
rested."
Rationale:
2. "I have learned how to massage my
1. MS patients should not exert them-
bladder to help empty my bladder com-
selves too much at one time. Space out
pletely."
activities and allow time for rest.
3. "I will take a hot bath in the evening to
2. Urinary retention is primarily treated by
help me relax if I have had a stressful day
medication (bethanochol), and exercises
at work."
can aid with it but are not the primary
4. "I should expect the blurred vision to
treatment
resolve after I have received medications
3. Hot temperatures are bad for MS and
for several weeks."
can worsen symptoms. Your nerves are
already fcked up and extra heat can
stress your body into overdrive
The nurse has attended a staff education
program about caring for clients who are
receiving positive pressure mechanical
ventilation. Which of the following state-
ments by the nurse would indicate a cor- 2. "Clients may develop stress ulcers and
rect understanding of the teaching? gastrointestinal bleeding."
1. "Clients should avoid range-of-motion Rationale: Postive Pressure Ventilation
(ROM) exercises until weaned from ven- may cause stress ulcers and GI bleeding
tilation." because
2. "Clients may develop stress ulcers and
gastrointestinal bleeding."
3. "Clients will be chemically paralyzed to
improve oxygenation."
, 4. "Clients will experience diuresis and
polyuria."
The charge nurse must transfer a female
client from the medical-surgical unit to
the maternity unit to make a bed avail-
able. It would be most appropriate for the
nurse to transfer the client who is
1. 28 years old, had a right mastectomy
and has a closed-wound drainage sys-
3. 56 years old, has hepatitis C (HCV)
tem
and has been afebrile for 24 hours
2. 49 years old, has diabetes mellitus
(type 2) and has begun receiving insulin
3. 56 years old, has hepatitis C (HCV)
and has been afebrile for 24 hours
4. 70 years old, has a fractured left tibia
and had an external fixation device ap-
plied 48 hours ago
The nurse has been made aware of
the following client situations. The nurse
should first assess the client with:
1. heart failure who has a productive
cough and is anxious
2. regional enteritis (Crohn's disease) 1. heart failure who has a productive
who is reporting cramping abdominal cough and is anxious
pain and diarrhea Productive cough (pink frothy sputum) in-
3. idiopathic thrombocytopenic purpura dicates pulmonary edema, anxiety might
(ITP) who has petechiae on the trunk be caused by decreased perfusion
and is reporting heavy menses
4. chronic obstructive pulmonary dis-
ease (COPD) who has dyspnea with ex-
ertion and is using accessory muscles to
breathe
The nurse and unlicensed assistive per-
sonnel (UAP) are caring for assigned
1. assisting a client with atrial fibrillation
clients. Which of the following tasks
to shower
would be appropriate for the nurse to
UAP can perform hygiene
assign to UAP?
1. assisting a client with atrial fibrillation
are occurring every 30 seconds
The charge nurse has received a Contractions should be no longer than
change-of-shift report on the following 90 secs and no closer than 2 mins (120
clients in labor. The charge nurse should secs)
ask a staff member to first see the client 90 secs is the duration, 2 mins is the
in the frequency.
1. first stage of labor who has an oral
temperature of 99.7° F (37.6° C) Rationale:
2. first stage of labor whose contractions 1. Elevated temp is normal during labor
are occurring every 30 seconds 3. Increased resps are normal during
3. second stage of labor who has respi- labor "pant-pant-blow" "hee-hee-hoo"
rations of 26 breathing pattern
4. second stage of labor whose contrac- 4. Contractions shouldn't be longer than
tions are lasting for 60 seconds 90 secs, 60 secs is okay and normal
Second stage: 2-3 mins apart, 60-90
secs long, 10 cm dilated, strong pain
The nurse is observing a staff member
2. placing a box of disposable face
caring for a client who has chickenpox.
shields outside the client's room
Which of the following actions by the
disposable face masks are not suitable
staff member would require the nurse to
for airborne precautions
intervene?
1. placing the client in a private room with
Rationale:
monitored negative air pressure
Varicella (chickenpox) is airborne pre-
2. placing a box of disposable face
caution. Private, negative pressure room,
shields outside the client's room
universal precautions (hand sanitizer in
3. placing an alcohol-based hand rub in
room) and placing surgical mask on
the client's room for hand hygiene
client during transport are all correct in-
4. placing a surgical mask on the client
terventions for Varicilla.
during transport out of the client's room
The nurse is caring for a client who re- 2. transcutaneous pacing
ports feeling faint and is experiencing the - external pacing that stimulates the ven-
cardiac rhythm shown in the electrocar- tricles to pump at a set rate
diogram (ECG) strip below. 5. Assess the client for angina
- BRADYCARDIA (it is more than 5 - Angina (Chest pain) can be caused
spaces apart, sinus rhythm) by both tachycardia (most common) and
Which of the following actions would be bradycardia (rare but can happen). As-
appropriate for the nurse to take? Select sessment of angina is appropriate
,all that apply:
Rationale:
1. Administer the client's prescribed beta
1. Beta blocker would further decrease
blocker.
HR
2. Prepare for transcutaneous pacing.
3. Valsalva maneuver/Vagal stimulation
3. Instruct the client to perform the Val-
would further decrease HR. (can be in-
salva maneuver.
dicated for sinus Tachy)
4. Begin chest compressions.
4. Chest compressions are for cardiac
5. Assess the client for angina.
arrest
1. Encourage the client to reminisce
about happy memories.
The nurse is planning care for a client
Its possible for AD patients to retain
with moderate Alzheimer's disease (AD).
long-term memories
Which of the following interventions
should the nurse include in the client's
Rationale:
plan of care?
2. Acknowledge feelings --> Redirect is
1. Encourage the client to reminisce
protocol for Dementia. Don't confront;
about happy memories.
they can't learn
2. Confront the client when inappropriate
3. AD is irreversible
or agitated behaviors occur.
4. In moderate AD, dementia has already
3. Administer to the client the
progressed to where pt needs help with
cholinesterase inhibitor to reverse the
ADLs and planning daily activities. Ask-
course of AD.
ing them to plan can frustrate them and
4. Provide the client with information
cause distress.
about activity choices in the morning so
STRUCTURED pleasant activities that
the client can make plans for the day.
consider the persons likes and interests
are the best.
The nurse is teaching a client how to 1. "Use your hands and arms to support
ambulate using crutches. Which of the your body weight."
following information should the nurse True! But watch out if it isn't 2-3 fin-
include? ger-widths, crutch paralysis can occur.
1. "Use your hands and arms to support s/s: paresis and paresthesias in wrists
your body weight." and hands
2. "Wear slippers when ambulating with
the crutches in your home." Rationales:
3. "Maintain the crutches 12 in (30 cm) in 2. Fall risk!
front of your feet while standing." 3. Should be 6 in. in front and 6 in. lateral
,4. "Adjust the hand grips of the crutches 4. Elbows should be bent at 30 degree
so that your elbows are fully extended." angle
4. "I should expect the blurred vision to
resolve after I have received medications
for several weeks."
The nurse has taught a client with multi-
MS causes nerve damage and can re-
ple sclerosis (MS).
sult in optic neuritis (vision loss, burry
Which of the following statements by the
vision). In most cases it resolves itself
client would indicate a correct under-
in 4-12 weeks, but medication (steroids)
standing of the teaching?
can speed up the process and resolve it
1. "I will complete all of my household
quicker
chores in the morning when I am well
rested."
Rationale:
2. "I have learned how to massage my
1. MS patients should not exert them-
bladder to help empty my bladder com-
selves too much at one time. Space out
pletely."
activities and allow time for rest.
3. "I will take a hot bath in the evening to
2. Urinary retention is primarily treated by
help me relax if I have had a stressful day
medication (bethanochol), and exercises
at work."
can aid with it but are not the primary
4. "I should expect the blurred vision to
treatment
resolve after I have received medications
3. Hot temperatures are bad for MS and
for several weeks."
can worsen symptoms. Your nerves are
already fcked up and extra heat can
stress your body into overdrive
The nurse has attended a staff education
program about caring for clients who are
receiving positive pressure mechanical
ventilation. Which of the following state-
ments by the nurse would indicate a cor- 2. "Clients may develop stress ulcers and
rect understanding of the teaching? gastrointestinal bleeding."
1. "Clients should avoid range-of-motion Rationale: Postive Pressure Ventilation
(ROM) exercises until weaned from ven- may cause stress ulcers and GI bleeding
tilation." because
2. "Clients may develop stress ulcers and
gastrointestinal bleeding."
3. "Clients will be chemically paralyzed to
improve oxygenation."
, 4. "Clients will experience diuresis and
polyuria."
The charge nurse must transfer a female
client from the medical-surgical unit to
the maternity unit to make a bed avail-
able. It would be most appropriate for the
nurse to transfer the client who is
1. 28 years old, had a right mastectomy
and has a closed-wound drainage sys-
3. 56 years old, has hepatitis C (HCV)
tem
and has been afebrile for 24 hours
2. 49 years old, has diabetes mellitus
(type 2) and has begun receiving insulin
3. 56 years old, has hepatitis C (HCV)
and has been afebrile for 24 hours
4. 70 years old, has a fractured left tibia
and had an external fixation device ap-
plied 48 hours ago
The nurse has been made aware of
the following client situations. The nurse
should first assess the client with:
1. heart failure who has a productive
cough and is anxious
2. regional enteritis (Crohn's disease) 1. heart failure who has a productive
who is reporting cramping abdominal cough and is anxious
pain and diarrhea Productive cough (pink frothy sputum) in-
3. idiopathic thrombocytopenic purpura dicates pulmonary edema, anxiety might
(ITP) who has petechiae on the trunk be caused by decreased perfusion
and is reporting heavy menses
4. chronic obstructive pulmonary dis-
ease (COPD) who has dyspnea with ex-
ertion and is using accessory muscles to
breathe
The nurse and unlicensed assistive per-
sonnel (UAP) are caring for assigned
1. assisting a client with atrial fibrillation
clients. Which of the following tasks
to shower
would be appropriate for the nurse to
UAP can perform hygiene
assign to UAP?
1. assisting a client with atrial fibrillation
