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The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. On
the basis of these findings, the nurse should implement which action?
1. Remove the IV.
2. Apply a warm compress.
3. Check for a blood return.
4. Measure the area of infiltration. - ANSWER ANSWER: 1
This question requires that you focus on the data in the question and determine that the
client is experiencing an infiltration. Next, you need to consider the harmful
effects of infiltration and determine the action to implement. Because infiltration can be
damaging to the surrounding tissue, the appropriate action is to remove the IV to prevent
any further damage. Once the IV is removed, further action should be taken depending on
the medication infusing at the time of infiltration based on agency protocol but may include
aspiration of the fluid from the site, injection of an antidote, application of warm or cool
compresses for specified time intervals, and elevation of the extremity.
The nurse has received the client assignment for the day. Which client should the nurse
assess first?
1. The client who needs to receive subcutaneous insulin before breakfast
2. The client who has a nasogastric tube attached to intermittent suction
3. The client who is 2 days postoperative and is complaining of incisional pain
4. The client who has a blood glucose level of 50 mg/dL (2.8 mmol/L) and complaints of
blurred vision - ANSWER ANSWER: 4
This question addresses the subcategory Management of Care in the Client Needs category
Safe and Effective Care Environment. Note the strategic word, first, so you
1
, need to establish priorities by comparing the needs of each client and deciding which need
is urgent. The client described in the correct option has a low blood
glucose level and symptoms reflective of hypoglycemia. This client should be assessed first
so that treatment can be implemented. Although the clients in options 1, 2, and 3 have
needs that require assessment, their assessments can wait until the
client in the correct option is stabilized.
The nurse prepares to care for a client on contact precautions who has a hospital-acquired
infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an
abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical
ventilator, which requires frequent suctioning. The nurse
should assemble which necessary protective items before entering the client's room?
1. Gloves and gown
2. Gloves and face shield
3. Gloves, gown, and face shield
4. Gloves, gown, and shoe protectors - ANSWER ANSWER: 3
This question addresses the subcategory Safety and Infection Control in the Client Needs
category Safe and Effective Care Environment. It addresses content related to protecting
oneself from contracting an infection and requires that you consider the methods of possible
transmission of infection, based on the client's condition. Note the data in the question.
Because of the potential for splashes of infective material occurring during the wound
irrigation or suctioning of the tracheostomy, option 3 is correct.
The nurse is choosing age-appropriate toys for a toddler. Which toy is the best choice for this
age?
1. Puzzle
2. Toy soldiers
3. Large stacking blocks
4. A card game with large pictures - ANSWER ANSWER: 3
This question addresses the Client Needs category Health Promotion and Maintenance and
specifically relates to the principles of growth and development of
2
The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. On
the basis of these findings, the nurse should implement which action?
1. Remove the IV.
2. Apply a warm compress.
3. Check for a blood return.
4. Measure the area of infiltration. - ANSWER ANSWER: 1
This question requires that you focus on the data in the question and determine that the
client is experiencing an infiltration. Next, you need to consider the harmful
effects of infiltration and determine the action to implement. Because infiltration can be
damaging to the surrounding tissue, the appropriate action is to remove the IV to prevent
any further damage. Once the IV is removed, further action should be taken depending on
the medication infusing at the time of infiltration based on agency protocol but may include
aspiration of the fluid from the site, injection of an antidote, application of warm or cool
compresses for specified time intervals, and elevation of the extremity.
The nurse has received the client assignment for the day. Which client should the nurse
assess first?
1. The client who needs to receive subcutaneous insulin before breakfast
2. The client who has a nasogastric tube attached to intermittent suction
3. The client who is 2 days postoperative and is complaining of incisional pain
4. The client who has a blood glucose level of 50 mg/dL (2.8 mmol/L) and complaints of
blurred vision - ANSWER ANSWER: 4
This question addresses the subcategory Management of Care in the Client Needs category
Safe and Effective Care Environment. Note the strategic word, first, so you
1
, need to establish priorities by comparing the needs of each client and deciding which need
is urgent. The client described in the correct option has a low blood
glucose level and symptoms reflective of hypoglycemia. This client should be assessed first
so that treatment can be implemented. Although the clients in options 1, 2, and 3 have
needs that require assessment, their assessments can wait until the
client in the correct option is stabilized.
The nurse prepares to care for a client on contact precautions who has a hospital-acquired
infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an
abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical
ventilator, which requires frequent suctioning. The nurse
should assemble which necessary protective items before entering the client's room?
1. Gloves and gown
2. Gloves and face shield
3. Gloves, gown, and face shield
4. Gloves, gown, and shoe protectors - ANSWER ANSWER: 3
This question addresses the subcategory Safety and Infection Control in the Client Needs
category Safe and Effective Care Environment. It addresses content related to protecting
oneself from contracting an infection and requires that you consider the methods of possible
transmission of infection, based on the client's condition. Note the data in the question.
Because of the potential for splashes of infective material occurring during the wound
irrigation or suctioning of the tracheostomy, option 3 is correct.
The nurse is choosing age-appropriate toys for a toddler. Which toy is the best choice for this
age?
1. Puzzle
2. Toy soldiers
3. Large stacking blocks
4. A card game with large pictures - ANSWER ANSWER: 3
This question addresses the Client Needs category Health Promotion and Maintenance and
specifically relates to the principles of growth and development of
2
