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. -
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. - 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. - 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. - 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.) - 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. - 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 Bwater.
D) Nasal Bcannula.
E) Flow Bmeter.
F) Lambs Bwool.
G) Tape. B- Banswer-D) BNasal Bcannula.
E) Flow Bmeter.
NGN: Bstates, BI Bam Bfeeling Bextremely Banxious Bright Bnow. BThe Bclient Bhas Bdecreased Bbreath Bsounds Bin Bthe
Bleft Blower Blow. BHis Bmucus Bmembranes Bare Bdry. BHe Bhas Ba Bproductive Bcough Bwith Bthick, Byellow
Bsecretions. BHis Bcapillary Brefill Bis Bfour Bseconds. BVital Bsigns, Btemperature B100.2. BHeart Brate B101 Bbpm,
Brespiratory Brate B28 Bbreaths Bper Bminute, Bblood Bpressure B145/89, Boxygen Bsaturation B90% Bon Broom Bair.
(for Beach Bbody Bsystem Bclick Bto Bspecify Bthe Bassessment Bfindings Bthat Bindicates Bhypoxia)
B Cardiovascular: Bheart Brate B100 Bbpm, Bcapillary Brefill Bfor Bseconds, Bblood Bpressure B145/89.
B Neurological: Banxious, Bawake Band Balert, Brestless.
Respiratory: Boxygen Bsaturation B90% Bon Broom Bair, Brespiratory Brate B28 Bbpm, Bproductive Bcough. B-
Banswer- BCardiovascular: Bcapillary Brefill Bfor Bseconds, Bblood Bpressure B145/89.
Neurological: Banxious, Brestless.
Respiratory: Boxygen Bsaturation B90% Bon Broom Bair, Brespiratory Brate B28 Bbpm.
NGN: BThe Bclient Bis Ba B49-year-old Bmale Bwho Breports Bflu Blike Bsymptoms Bincluding Bfever Band Bchest
Bcongestion Bfor Bfour Bdays. BHe Bcame Bto Bthe Bemergency Bdepartment Blast Bnight Bwhen Bhe Bwas Bhaving
Bmore Bdifficulty Bbreathing Bhe Bhas Ba Bhistory Bof B1/2 Bpack Ba Bday Bcigarette Bsmoking Bfor B20 Byears. BHe
Bhas Bno Bsignificant Bmedical Bor Bsurgical Bhistory.
The Bnurse Bshould Bplace Bthe Bclient Bin Ba B position Bto Bpromote B . B- Banswer-
BSemi-Fowler B, Blung Bexpansion.
NGN: BOrders: B0330: Bplace Bthe Bclient Bon Ba Bcardio Brespiratory Bmonitor, BNPO, Bsputum Bculture, Bstart Ba
BPIV, Bstart Boxygen B3L Bvia Bnasal Bcannula, Bnormal Bsaline B150 BML Bper Bhour, Bacetaminophen B350mg BPO
Bevery Bsix Bhours Bfor Btemp Bgreater Bthan B101F, Bchest Bx-ray.
0500: BOxygen B8Lvia Bsimple Bfacemask, Btitrate Bto Bkeep Boxygen Bsaturation Bgreater Bthan B94%.
(mark Bwhether Bthe Bstatements Bby Bthe Bnew Bgrad Bnurse Bindicate Bunderstanding Bor Bno Bunderstanding Bof
Bthe Buse Bof Bfacemask Bin Bthe Bcare Bof Bthis Bclient)
, -I Bshould Bclean Bthe Bfacemask Bonce Bper Bshift.
-The Bclient Bshould Btake Ba B1 Bto B2 Bminute Bbreak Bfrom Bthe Bfacemask Beach Bhour.
-I Bshould Bput Bgauze Bunder Bthe Belastic Bstraps Bover Bthe Bears.
-I Bcan Badjust Bthe Boxygen Blevel Bon Bthe Bflow Bmeter Bto Bkeep Bthe Bclients Boxygen Bsaturation Bgreater Bthan
B94%.
-The Bmask Bshould Bcover Bonly Bthe Bmouth Band Bleave Bthe Bnose Bopen Bfor Bexpiration.
-I Bshould Bplace Bthe Bmask Bfirst Bover Bthe Bnose Band Bthen Bcover Bthe Bmouth. B- Banswer--I Bshould Bclean Bthe
Bfacemask Bonce Bper Bshift. B(UNDERSTANDING)
-The Bclient Bshould Btake Ba B1 Bto B2 Bminute Bbreak Bfrom Bthe Bfacemask Beach Bhour. B(NOT BUNDERSTANDING)
-I Bshould Bput Bgauze Bunder Bthe Belastic Bstraps Bover Bthe Bears. B(NOT BUNDERSTANDING B????)
-I Bcan Badjust Bthe Boxygen Blevel Bon Bthe Bflow Bmeter Bto Bkeep Bthe Bclients Boxygen Bsaturation Bgreater Bthan
B94%. B(UNDERSTANDING)
-The Bmask Bshould Bcover Bonly Bthe Bmouth Band Bleave Bthe Bnose Bopen Bfor Bexpiration. B(NOT
BUNDERSTANDING)
-I Bshould Bplace Bthe Bmask Bfirst Bover Bthe Bnose Band Bthen Bcover Bthe Bmouth. B(UNDERSTANDING)
NGN: BNurses BNotes: B0400, Bthe Bclient Bis Bawake Band Balert Bbut Brestless. BHe Bstates BI Bam Bfeeling
Bextremely Banxious Bright Bnow. BThe Bclient Bhas Bdecreased Bbreath Bsounds Bin Bthe Bleft Blower Blobe. BHis
Bmucus Bmembranes Bare Bdry. BHe Bhas Ba Bproductive Bcough Bwith Bthick, Byellow Bsecretions. BHis Bcapillary
Brefill Bis Bfour Bseconds. BHeart Brate B101 BBPM, Boxygen Bsaturation B90%. BBlood Bpressure B145/89,
Btemperature B100.2 BF, Brespiratory Brate B28 BBPM.
0500: BPlacedthe Bclient Bin Bsemi-Fowlers Bposition. BNo Bimprovement Bin Boxygen Bsaturation Bon B3L Bnasal
Bcannula...
(Which Bare Bthe Bthree Bmost Bimportant Bgoals?)
A) The Bclient Bwill Bremain Bfree Bof Bskin Bbreakdown.
B) The Bclient Bwill Bhave Bquit Bsmoking.
C) The Bclient Bwill Bbe Bafebrile Bfor B24 Bhours.
D) The Bclient Bwill Bmaintain Boxygen Bsaturation Bof B96% Bwithout Bsupplemental Boxygen.
E) The Bclient Bwill Breport Bpain Bless Bthan B3/10. B- Banswer-B) BThe Bclient Bwill Bhave Bquit Bsmoking.
C) BThe Bclient Bwill Bbe Bafebrile Bfor B24 Bhours.
E) BThe Bclient Bwill Breport Bpain Bless Bthan B3/10.
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. -
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. - 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. - 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. - 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.) - 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. - 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 Bwater.
D) Nasal Bcannula.
E) Flow Bmeter.
F) Lambs Bwool.
G) Tape. B- Banswer-D) BNasal Bcannula.
E) Flow Bmeter.
NGN: Bstates, BI Bam Bfeeling Bextremely Banxious Bright Bnow. BThe Bclient Bhas Bdecreased Bbreath Bsounds Bin Bthe
Bleft Blower Blow. BHis Bmucus Bmembranes Bare Bdry. BHe Bhas Ba Bproductive Bcough Bwith Bthick, Byellow
Bsecretions. BHis Bcapillary Brefill Bis Bfour Bseconds. BVital Bsigns, Btemperature B100.2. BHeart Brate B101 Bbpm,
Brespiratory Brate B28 Bbreaths Bper Bminute, Bblood Bpressure B145/89, Boxygen Bsaturation B90% Bon Broom Bair.
(for Beach Bbody Bsystem Bclick Bto Bspecify Bthe Bassessment Bfindings Bthat Bindicates Bhypoxia)
B Cardiovascular: Bheart Brate B100 Bbpm, Bcapillary Brefill Bfor Bseconds, Bblood Bpressure B145/89.
B Neurological: Banxious, Bawake Band Balert, Brestless.
Respiratory: Boxygen Bsaturation B90% Bon Broom Bair, Brespiratory Brate B28 Bbpm, Bproductive Bcough. B-
Banswer- BCardiovascular: Bcapillary Brefill Bfor Bseconds, Bblood Bpressure B145/89.
Neurological: Banxious, Brestless.
Respiratory: Boxygen Bsaturation B90% Bon Broom Bair, Brespiratory Brate B28 Bbpm.
NGN: BThe Bclient Bis Ba B49-year-old Bmale Bwho Breports Bflu Blike Bsymptoms Bincluding Bfever Band Bchest
Bcongestion Bfor Bfour Bdays. BHe Bcame Bto Bthe Bemergency Bdepartment Blast Bnight Bwhen Bhe Bwas Bhaving
Bmore Bdifficulty Bbreathing Bhe Bhas Ba Bhistory Bof B1/2 Bpack Ba Bday Bcigarette Bsmoking Bfor B20 Byears. BHe
Bhas Bno Bsignificant Bmedical Bor Bsurgical Bhistory.
The Bnurse Bshould Bplace Bthe Bclient Bin Ba B position Bto Bpromote B . B- Banswer-
BSemi-Fowler B, Blung Bexpansion.
NGN: BOrders: B0330: Bplace Bthe Bclient Bon Ba Bcardio Brespiratory Bmonitor, BNPO, Bsputum Bculture, Bstart Ba
BPIV, Bstart Boxygen B3L Bvia Bnasal Bcannula, Bnormal Bsaline B150 BML Bper Bhour, Bacetaminophen B350mg BPO
Bevery Bsix Bhours Bfor Btemp Bgreater Bthan B101F, Bchest Bx-ray.
0500: BOxygen B8Lvia Bsimple Bfacemask, Btitrate Bto Bkeep Boxygen Bsaturation Bgreater Bthan B94%.
(mark Bwhether Bthe Bstatements Bby Bthe Bnew Bgrad Bnurse Bindicate Bunderstanding Bor Bno Bunderstanding Bof
Bthe Buse Bof Bfacemask Bin Bthe Bcare Bof Bthis Bclient)
, -I Bshould Bclean Bthe Bfacemask Bonce Bper Bshift.
-The Bclient Bshould Btake Ba B1 Bto B2 Bminute Bbreak Bfrom Bthe Bfacemask Beach Bhour.
-I Bshould Bput Bgauze Bunder Bthe Belastic Bstraps Bover Bthe Bears.
-I Bcan Badjust Bthe Boxygen Blevel Bon Bthe Bflow Bmeter Bto Bkeep Bthe Bclients Boxygen Bsaturation Bgreater Bthan
B94%.
-The Bmask Bshould Bcover Bonly Bthe Bmouth Band Bleave Bthe Bnose Bopen Bfor Bexpiration.
-I Bshould Bplace Bthe Bmask Bfirst Bover Bthe Bnose Band Bthen Bcover Bthe Bmouth. B- Banswer--I Bshould Bclean Bthe
Bfacemask Bonce Bper Bshift. B(UNDERSTANDING)
-The Bclient Bshould Btake Ba B1 Bto B2 Bminute Bbreak Bfrom Bthe Bfacemask Beach Bhour. B(NOT BUNDERSTANDING)
-I Bshould Bput Bgauze Bunder Bthe Belastic Bstraps Bover Bthe Bears. B(NOT BUNDERSTANDING B????)
-I Bcan Badjust Bthe Boxygen Blevel Bon Bthe Bflow Bmeter Bto Bkeep Bthe Bclients Boxygen Bsaturation Bgreater Bthan
B94%. B(UNDERSTANDING)
-The Bmask Bshould Bcover Bonly Bthe Bmouth Band Bleave Bthe Bnose Bopen Bfor Bexpiration. B(NOT
BUNDERSTANDING)
-I Bshould Bplace Bthe Bmask Bfirst Bover Bthe Bnose Band Bthen Bcover Bthe Bmouth. B(UNDERSTANDING)
NGN: BNurses BNotes: B0400, Bthe Bclient Bis Bawake Band Balert Bbut Brestless. BHe Bstates BI Bam Bfeeling
Bextremely Banxious Bright Bnow. BThe Bclient Bhas Bdecreased Bbreath Bsounds Bin Bthe Bleft Blower Blobe. BHis
Bmucus Bmembranes Bare Bdry. BHe Bhas Ba Bproductive Bcough Bwith Bthick, Byellow Bsecretions. BHis Bcapillary
Brefill Bis Bfour Bseconds. BHeart Brate B101 BBPM, Boxygen Bsaturation B90%. BBlood Bpressure B145/89,
Btemperature B100.2 BF, Brespiratory Brate B28 BBPM.
0500: BPlacedthe Bclient Bin Bsemi-Fowlers Bposition. BNo Bimprovement Bin Boxygen Bsaturation Bon B3L Bnasal
Bcannula...
(Which Bare Bthe Bthree Bmost Bimportant Bgoals?)
A) The Bclient Bwill Bremain Bfree Bof Bskin Bbreakdown.
B) The Bclient Bwill Bhave Bquit Bsmoking.
C) The Bclient Bwill Bbe Bafebrile Bfor B24 Bhours.
D) The Bclient Bwill Bmaintain Boxygen Bsaturation Bof B96% Bwithout Bsupplemental Boxygen.
E) The Bclient Bwill Breport Bpain Bless Bthan B3/10. B- Banswer-B) BThe Bclient Bwill Bhave Bquit Bsmoking.
C) BThe Bclient Bwill Bbe Bafebrile Bfor B24 Bhours.
E) BThe Bclient Bwill Breport Bpain Bless Bthan B3/10.
