,The nurse is assessing a client with dark skin who is in Respiratory Distress. Which
client response should the nurse evaluate to determine cyanosis in this particular client?
A. Cyanosis in a client with dark skin is seen in the sclera
B. Abnormal skin color changes in a client with dark skin cannot be determined
C. The lips and mucus membranes of a client with dark skin are dusky in color
D. Blanching the soles of the feet in a client with dark skin reveals cyanosis -
CORRECT ANSWERS-C. The lips and mucus membranes of a client with dark skin are
dusky in color
Causes of cyanosis include hypoxemia and decreased cardiac output, which provides
clues to respiratory status with changes in skin color and mucous membranes.
Cyanosis, a late sign of hypoxemia, is best observed in tissue that has superficial
capillary supply, such as mucous membranes, the conjunctiva, lips, palms, and under
the tongue, which is readily visible in dark skin
Which technique should the PN use to most accurately assess a client's baseline BP
during a routine health exam?
A. Measure the pressure in each arm while the client sits with both arms supported at
heart level
B. Calculate avg BP using readings obtained in both arms
C. Obtain BP first with client lying supine and then when standing
D. Take additional measurements for readings with a 10 mm Hg difference - CORRECT
ANSWERS-A. Measure the pressure in each arm while the client sits with both arms
supported at heart level
BP should be taken initially in both arms while the client is seated or supine with the arm
bared, supported, and positioned at the level of the heart
A client with gastroenteritis, nausea, and vomiting is currently on Nothing by mouth
(NPO) status. The healthcare provider prescribes oral intake to be advanced as
tolerated. Which fluid should the practical nurse offer first?
A. Tea
B. Broth
C. Water
D. Soda - CORRECT ANSWERS-C. Water
Water or ice chips are the first choices of clear fluids for rehydration by mouth
An older client who is admitted to the hospital with dehydration and electrolyte
imbalance is confused and incontinent of urine. Which action provides the best strategy
for the practical nurse (PN) to implement for the client's incontinence?
, A. Insert an indwelling urinary catheter
B. Apply absorbent incontinence pads
C. Restrict fluids after the evening meal
D. Establish a 2-hour voiding schedule - CORRECT ANSWERS-D. Establish a 2-hour
voiding schedule
A 2 hour voiding schedule is the best strategy for urinary incontinence management b/c
it provides the client who is confused an opportunity to empty the bladder which
minimizes incontinence due to overfilling
Which intervention should the practical nurse (PN) implement to reduce the incidence of
urinary tract infections in a client with an indwelling catheter?
A. Irrigate cath with sterile distilled water
B. Dilute an antiseptic solution in the perineal wash
C. Cleanse perineal area with soap and water BID and PRN
D. Apply an antibiotic ointment around urinary meatus BID - CORRECT ANSWERS-C.
Cleanse perineal area with soap and water BID and PRN
Daily perineal care BID and PRN should include cleansing of the meatus and catheter
junction with soap and water
A male client is upset with the healthcare provider's recommendation that he should
consent to an above-knee amputation. He tells the practical nurse (PN), if they want to
cut off my leg, they should just shoot me instead. How should the PN respond?
A. Ask the client how the surgery might effect his lifestyle
B. Offer to stay with the client wile he makes his decision
C. Express sympathy that there is no other choice possible
D. Explain how many others function well with a prosthesis - CORRECT ANSWERS-A.
Ask the client how the surgery might effect his lifestyle
Limb amputation alters body image and changes the client's ADLs, work, and
recreational activities, which triggers a grieving process for the client. Determining the
client's perception of the procedure's impact on his lifestyle is therapeutic and allows the
client to explore and discuss feelings
A client with cancer who has been taking opioid analgesics for two years now requires
increased doses to obtain pain relief. he client expresses fear about becoming addicted
to these drugs. What information should the practical nurse (PN) provide?
A. Opioid use with cancer does not cause addiction
B. Addiction is easily reversed if it occurs during pain management
C. Prescribed opiates for cancer pain relief improves quality of life
D. Opiate dosages can be tapered is a client fears addiction - CORRECT ANSWERS-C.
Prescribed opiates for cancer pain relief improves quality of life
client response should the nurse evaluate to determine cyanosis in this particular client?
A. Cyanosis in a client with dark skin is seen in the sclera
B. Abnormal skin color changes in a client with dark skin cannot be determined
C. The lips and mucus membranes of a client with dark skin are dusky in color
D. Blanching the soles of the feet in a client with dark skin reveals cyanosis -
CORRECT ANSWERS-C. The lips and mucus membranes of a client with dark skin are
dusky in color
Causes of cyanosis include hypoxemia and decreased cardiac output, which provides
clues to respiratory status with changes in skin color and mucous membranes.
Cyanosis, a late sign of hypoxemia, is best observed in tissue that has superficial
capillary supply, such as mucous membranes, the conjunctiva, lips, palms, and under
the tongue, which is readily visible in dark skin
Which technique should the PN use to most accurately assess a client's baseline BP
during a routine health exam?
A. Measure the pressure in each arm while the client sits with both arms supported at
heart level
B. Calculate avg BP using readings obtained in both arms
C. Obtain BP first with client lying supine and then when standing
D. Take additional measurements for readings with a 10 mm Hg difference - CORRECT
ANSWERS-A. Measure the pressure in each arm while the client sits with both arms
supported at heart level
BP should be taken initially in both arms while the client is seated or supine with the arm
bared, supported, and positioned at the level of the heart
A client with gastroenteritis, nausea, and vomiting is currently on Nothing by mouth
(NPO) status. The healthcare provider prescribes oral intake to be advanced as
tolerated. Which fluid should the practical nurse offer first?
A. Tea
B. Broth
C. Water
D. Soda - CORRECT ANSWERS-C. Water
Water or ice chips are the first choices of clear fluids for rehydration by mouth
An older client who is admitted to the hospital with dehydration and electrolyte
imbalance is confused and incontinent of urine. Which action provides the best strategy
for the practical nurse (PN) to implement for the client's incontinence?
, A. Insert an indwelling urinary catheter
B. Apply absorbent incontinence pads
C. Restrict fluids after the evening meal
D. Establish a 2-hour voiding schedule - CORRECT ANSWERS-D. Establish a 2-hour
voiding schedule
A 2 hour voiding schedule is the best strategy for urinary incontinence management b/c
it provides the client who is confused an opportunity to empty the bladder which
minimizes incontinence due to overfilling
Which intervention should the practical nurse (PN) implement to reduce the incidence of
urinary tract infections in a client with an indwelling catheter?
A. Irrigate cath with sterile distilled water
B. Dilute an antiseptic solution in the perineal wash
C. Cleanse perineal area with soap and water BID and PRN
D. Apply an antibiotic ointment around urinary meatus BID - CORRECT ANSWERS-C.
Cleanse perineal area with soap and water BID and PRN
Daily perineal care BID and PRN should include cleansing of the meatus and catheter
junction with soap and water
A male client is upset with the healthcare provider's recommendation that he should
consent to an above-knee amputation. He tells the practical nurse (PN), if they want to
cut off my leg, they should just shoot me instead. How should the PN respond?
A. Ask the client how the surgery might effect his lifestyle
B. Offer to stay with the client wile he makes his decision
C. Express sympathy that there is no other choice possible
D. Explain how many others function well with a prosthesis - CORRECT ANSWERS-A.
Ask the client how the surgery might effect his lifestyle
Limb amputation alters body image and changes the client's ADLs, work, and
recreational activities, which triggers a grieving process for the client. Determining the
client's perception of the procedure's impact on his lifestyle is therapeutic and allows the
client to explore and discuss feelings
A client with cancer who has been taking opioid analgesics for two years now requires
increased doses to obtain pain relief. he client expresses fear about becoming addicted
to these drugs. What information should the practical nurse (PN) provide?
A. Opioid use with cancer does not cause addiction
B. Addiction is easily reversed if it occurs during pain management
C. Prescribed opiates for cancer pain relief improves quality of life
D. Opiate dosages can be tapered is a client fears addiction - CORRECT ANSWERS-C.
Prescribed opiates for cancer pain relief improves quality of life
