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When preparing to administer a prescribed medication to a homeless client at a community psychiatric
clinic. The client tells the nurse that the usual dosage taken is different from the dose the nurse is giving.
Which action should the nurse take?
A) Inform the client that he may refuse the medication and document whether or not the client takes it.
B) Withhold the medication until the dosage can be confirmed.
C) Explain to the client that the dosage has been changed.
D) Tell the client to take the medication then verify the dosage at the next healthcare team meeting. -
CORRECT ANSWER-B) Withhold the medication until the dosage can be confirmed.
The charge nurse is making assignments for one practical nurse and three registered nurses who are
caring for neurologically compromised clients. Which client with which change in status is best to assign
to the PN?
A) Subdural hematoma whose blood pressure changed from 150/80 to 170/60.
B) Viral meningitis whose temperature change from 101 S to 102F.
C) Diabetic keto acidosis who is Glasgow coma scale score changed from 10 to 7.
D) Myxedema, whose blood pressure change from 80/50 to 70/40. - CORRECT ANSWER-B) Viral
meningitis whose temperature change from 101 S to 102F.
The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi
organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most
important for the nurse to include in the plan of care?
A) Maintain strict intake and output.
B) Keep head of bed raised 45°.
C) Excess warmth of extremities.
D) Monitor blood glucose level. - CORRECT ANSWER-A) Maintain strict intake and output.
,And adolescent client is admitted to the hospital because of writing a suicide note to a teacher at school.
On the second day of hospitalization, the nurse asked the client to meet with the treatment team. After
the team meeting, the client leaves in tears and goes to their room. Which nursing intervention is best?
A) Let the client rest quietly in their room for a while.
B) Explore the clients goals and desire for treatment.
C) Ask the treatment team about the clients behavior.
D) Go to the clients room and ask what happened. - CORRECT ANSWER-D) Go to the clients room and
ask what happened.
The healthcare provider prescribes dalteparin 200 units per kilogram subcutaneous once a day for a
client who weighs 154 pounds. The medication is available and 25,000 units per milliliter vial. How many
milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the
nearest 10th.) - CORRECT ANSWER-0.6
NGN: The client is a 49-year-old male who reports flu like symptoms including fever and chest
congestion for four days. He came to the emergency department last night when he was having more
difficulty breathing he has a history of 1/2 pack a day cigarette smoking for 20 years. He has no
significant medical or surgical history.
Which two orders should the nurse complete first?
A) Sputum culture.
B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
D) Chest x-ray.
E) Acetominophen 350 mg PO every six hours for temperature control.
F) Run 0.9% sodium chloride IV infusion at 150 mL per hour.
G) Start peripheral IV.
H) NPO. - CORRECT ANSWER-B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
NGN: 0330: place the client on a cardio respiratory monitor, NPO, sputum culture, start a peripheral IV
infusion, start oxygen 3 L per minute via nasal cannula, begin 0.9% sodium chloride IV infusion at 150 mL
per hour, acetaminophen 350 mg PO every six hours for temperature.
,To start the client on oxygen as ordered which items should the nurse collects from the supply room?
SATA
A) humidifier bottle.
B)Suction canister.
C)Sterile water.
D) Nasal cannula.
E) Flow meter.
F) Lambs wool.
G) Tape. - CORRECT ANSWER-D) Nasal cannula.
E) Flow meter.
The nurse should place the client in a _______________ position to promote _____________. -
CORRECT ANSWER-Semi-Fowler , lung expansion.
NGN: Orders: 0330: place the client on a cardio respiratory monitor, NPO, sputum culture, start a PIV,
start oxygen 3L via nasal cannula, normal saline 150 ML per hour, acetaminophen 350mg PO every six
hours for temp greater than 101F, chest x-ray.
0500: Oxygen 8Lvia simple facemask, titrate to keep oxygen saturation greater than 94%.
The nurse has completed the diet teaching of a client who is being discharged following treatment of a
leg wound. A high-protein diet is encouraged to promote wound healing. Which lunch toys by the client
indicates that the teaching was effective?
A) A peanut butter sandwich with soda and cookies.
B) Vegetable soup, crackers, and milk.
C) A tuna fish sandwich with chips and ice cream.
D) A salad with three kinds of lettuce and fruit. - CORRECT ANSWER-C) A tuna fish sandwich with chips
and ice cream.
A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected
MRSA. Which nursing intervention should the nurse include in the plan of care? SATA.
A) Institute contact precautions for staff and visitors.
B) Use standard precautions and wear a mask.
C) Send wound drainage for culture and sensitivity.
, D) Monitor the clients white blood cell count.
E) Explain the purpose of a low bacteria diet. - CORRECT ANSWER-A) Institute contact precautions for
staff and visitors.
C) Send wound drainage for culture and sensitivity.
D) Monitor the clients white blood cell count.
An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly
slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse
to report to the healthcare provider?
A) Weight loss of 10 pounds in the past month.
B) Six hours of sleep in the past three days.
C) Blood alcohol level of 0.09%.
D) Serum lithium level of 1.6. - CORRECT ANSWER-D) Serum lithium level of 1.6.
When conducting diet teaching for a client who is on a post operative full liquid diet, which foods should
the nurse encouraged the client to eat? SATA.
A) Clear beef broth.
B) Vanilla frozen yogurt.
C) Vegetable juice.
D) Creamy peanut butter.
E) Canned fruit cocktail. - CORRECT ANSWER-A) Clear beef broth.
B) Vanilla frozen yogurt.
C) Vegetable juice.
An infant born with esophageal atresia and tracheoesophageal fistula receives a prescription for internal
feedings after corrective surgery. To promote normal growth and development of the infant, which
action should the nurse include in the plan of care? - CORRECT ANSWER-Offer a pacifier for non-
Nutritive sucking
The nurse is preparing a four year-old client with a serum bilirubin level of 19 for discharge from the
hospital. When teaching the parents about home photo therapy, which instruction should the nurse
include in the discharge teaching plan?