A client with chronic pancreatitis has been taking pancreatin with meals. How does the nurse assist with
evaluating the effectiveness of the treatment?
a. The client has no further gallstones.
b. The powder is well mixed with applesauce.
c. The client’s blood sugar remains in normal range.
d. The client’s stools remain soft and medium brown in color.
d. The client’s stools remain soft and medium brown in color.
Rationale:
The client taking pancreatin should have stools that are soft and medium brown in color. If the
pancreatic enzyme replacement is not effective, the stools would be loose, frequent, and have a fatty
consistency. Pancreatin will not prevent gallstones, nor stabilize the blood sugars. It is important that
the pancreatin powder be mixed well with applesauce, but ensuring it is mixed well will not
determine effectiveness of the medication.
A client is walking in the hallway and begins experiencing an acute angina attack. Which is the first
action for the nurse to take?
a. Administer a nitroglycerine tablet sublingually.
b. Notify the local emergency medical services. (EMS).
c. Assist the client to walk back to the client’s room.
d. Ask the client if this attack occurred at the same time as yesterday’s.
a. Administer a nitroglycerine tablet sublingually.
Rationale:
,2|P age
The first action is to administer nitroglycerine sublingually, in order to dilate the coronary arteries so
that more oxygenated blood can be provided to the myocardium. It is not necessary to notify EMS
unless the angina pain is unrelieved by three nitroglycerine tablets. The client should rest
immediately, not walk back to the room. It is not a priority to determine whether or not the attack
occurred at the same time as yesterday’s.
The nurse has reviewed the plan of care for a client with rheumatoid arthritis (RA) to a group of
unlicensed assistive personnel (UAPs). Which comment by the UAP indicates the need for further
teaching?
a. “We should bathe the client when she feels most energetic.”
b. “We can turn on the television if she wants it when she is in pain.”
c. “We can use ice packs wrapped in washcloths to apply to painful joints.”
d. “When she is walking with us, we should remind her not to use jerky movements.”
c. “We can use ice packs wrapped in washcloths to apply to painful joints.”
Rationale:
A client with RA will benefit from warm moist heat, whirlpool baths, and warm showers. Ice would
likely cause more discomfort. The client should be bathed when she feels most energetic. Distraction
can somewhat reduce pain, and television can be used if the client prefers it. The UAPs can remind the
client to walk with slow, smooth motions.
A client diagnosed with prostate cancer is prescribed radioactive seed implantation (brachytherapy).
What is the most important nursing action for the practical nurse (PN) to do?
a. Follow radiation exposure precautions.
b. Encourage regular meals.
c. Collect all urine in sealed containers.
d. Avoid touching the client.
a. Follow radiation exposure precautions.
Rationale:
Clients being treated for prostate cancer with brachytherapy (radioactive seeds implant) should be
placed on radiation exposure precautions. The PN needs to follow the institution’s protocols put in
place regarding the amount of time and distance needed to prevent excessive exposure that would
pose a hazard to others.
The practical nurse is preparing a room for a client being admitted from the emergency department with
a diagnosis of new onset of seizures. Which intervention should the nurse implement first?
a. Ensure there is an IV pump and it is functioning properly.
b. Set-up and check for functioning of a suction apparatus and oxygen delivery system at bedside.
,3|P age
c. Placement of a padded tongue blade above the head of bed on wall.
d. Presence of the call button and television remote at the head of bed.
b. Set-up and check for functioning of a suction apparatus and oxygen delivery system at bedside.
Rationale:
Maintaining the airway during a seizure is a priority for safety. The practical nurse needs to ensure
there is a functioning suction apparatus to ensure airway clearance and an oxygen delivery system at
bedside in the event of a seizure.
A practical nurse (PN) reinforced client teaching regarding the transmission of the HIV virus. Which
statement by the client demonstrates an understanding of the reinforced teaching?
a. “To be absolutely safe, I should wear two latex condoms during intercourse with an infected partner.”
b. “I may still contract HIV even though I am 62 years old.”
c. “Urinating immediately after having sexual relations will help reduce the risk of contracting HIV.”
d. “If I take AZT during my pregnancy, I will not give the virus to my unborn baby.”
b. “I may still contract HIV even though I am 62 years old.”
Rationale:
More than 10% of all AIDS cases in the United States are among those older than 50 years of age.
The nurse is caring for a client who has an ileostomy and has reinforced instructions regarding ileostomy
care. The nurse realizes the client needs additional instructions if the client makes which statement?
a. “I should avoid high-fiber foods such as bran flakes.”
b. “I will need to empty the ostomy pouch when it is half full.”
c. “I will need to set a time every day when I can irrigate the ostomy.”
d. “I can use a simple squirt bottle to rinse out the pouch to remove odors.”
c. “I will need to set a time every day when I can irrigate the ostomy.”
Rationale:
The client will not be able to set a time to irrigate the ostomy because the ileostomy drains all the
time. A client who has had an ostomy placed on the descending colon will most likely need to irrigate
the ostomy at the same time each day. High-fiber foods will cause diarrhea. The client will need to
empty the ostomy pouch when it is one-third to one-half full. Water and a simple squirt bottle can be
used to remove effluence from the pouch and reduce odors.
A client status post-cholecystectomy 3 days is being prepared to be discharged home. Which client
finding is the best indication to the practical nurse that postoperative nursing interventions have
prevented respiratory complications?
1 M| MP M a M g M e
,
evaluating the effectiveness of the treatment?
a. The client has no further gallstones.
b. The powder is well mixed with applesauce.
c. The client’s blood sugar remains in normal range.
d. The client’s stools remain soft and medium brown in color.
d. The client’s stools remain soft and medium brown in color.
Rationale:
The client taking pancreatin should have stools that are soft and medium brown in color. If the
pancreatic enzyme replacement is not effective, the stools would be loose, frequent, and have a fatty
consistency. Pancreatin will not prevent gallstones, nor stabilize the blood sugars. It is important that
the pancreatin powder be mixed well with applesauce, but ensuring it is mixed well will not
determine effectiveness of the medication.
A client is walking in the hallway and begins experiencing an acute angina attack. Which is the first
action for the nurse to take?
a. Administer a nitroglycerine tablet sublingually.
b. Notify the local emergency medical services. (EMS).
c. Assist the client to walk back to the client’s room.
d. Ask the client if this attack occurred at the same time as yesterday’s.
a. Administer a nitroglycerine tablet sublingually.
Rationale:
,2|P age
The first action is to administer nitroglycerine sublingually, in order to dilate the coronary arteries so
that more oxygenated blood can be provided to the myocardium. It is not necessary to notify EMS
unless the angina pain is unrelieved by three nitroglycerine tablets. The client should rest
immediately, not walk back to the room. It is not a priority to determine whether or not the attack
occurred at the same time as yesterday’s.
The nurse has reviewed the plan of care for a client with rheumatoid arthritis (RA) to a group of
unlicensed assistive personnel (UAPs). Which comment by the UAP indicates the need for further
teaching?
a. “We should bathe the client when she feels most energetic.”
b. “We can turn on the television if she wants it when she is in pain.”
c. “We can use ice packs wrapped in washcloths to apply to painful joints.”
d. “When she is walking with us, we should remind her not to use jerky movements.”
c. “We can use ice packs wrapped in washcloths to apply to painful joints.”
Rationale:
A client with RA will benefit from warm moist heat, whirlpool baths, and warm showers. Ice would
likely cause more discomfort. The client should be bathed when she feels most energetic. Distraction
can somewhat reduce pain, and television can be used if the client prefers it. The UAPs can remind the
client to walk with slow, smooth motions.
A client diagnosed with prostate cancer is prescribed radioactive seed implantation (brachytherapy).
What is the most important nursing action for the practical nurse (PN) to do?
a. Follow radiation exposure precautions.
b. Encourage regular meals.
c. Collect all urine in sealed containers.
d. Avoid touching the client.
a. Follow radiation exposure precautions.
Rationale:
Clients being treated for prostate cancer with brachytherapy (radioactive seeds implant) should be
placed on radiation exposure precautions. The PN needs to follow the institution’s protocols put in
place regarding the amount of time and distance needed to prevent excessive exposure that would
pose a hazard to others.
The practical nurse is preparing a room for a client being admitted from the emergency department with
a diagnosis of new onset of seizures. Which intervention should the nurse implement first?
a. Ensure there is an IV pump and it is functioning properly.
b. Set-up and check for functioning of a suction apparatus and oxygen delivery system at bedside.
,3|P age
c. Placement of a padded tongue blade above the head of bed on wall.
d. Presence of the call button and television remote at the head of bed.
b. Set-up and check for functioning of a suction apparatus and oxygen delivery system at bedside.
Rationale:
Maintaining the airway during a seizure is a priority for safety. The practical nurse needs to ensure
there is a functioning suction apparatus to ensure airway clearance and an oxygen delivery system at
bedside in the event of a seizure.
A practical nurse (PN) reinforced client teaching regarding the transmission of the HIV virus. Which
statement by the client demonstrates an understanding of the reinforced teaching?
a. “To be absolutely safe, I should wear two latex condoms during intercourse with an infected partner.”
b. “I may still contract HIV even though I am 62 years old.”
c. “Urinating immediately after having sexual relations will help reduce the risk of contracting HIV.”
d. “If I take AZT during my pregnancy, I will not give the virus to my unborn baby.”
b. “I may still contract HIV even though I am 62 years old.”
Rationale:
More than 10% of all AIDS cases in the United States are among those older than 50 years of age.
The nurse is caring for a client who has an ileostomy and has reinforced instructions regarding ileostomy
care. The nurse realizes the client needs additional instructions if the client makes which statement?
a. “I should avoid high-fiber foods such as bran flakes.”
b. “I will need to empty the ostomy pouch when it is half full.”
c. “I will need to set a time every day when I can irrigate the ostomy.”
d. “I can use a simple squirt bottle to rinse out the pouch to remove odors.”
c. “I will need to set a time every day when I can irrigate the ostomy.”
Rationale:
The client will not be able to set a time to irrigate the ostomy because the ileostomy drains all the
time. A client who has had an ostomy placed on the descending colon will most likely need to irrigate
the ostomy at the same time each day. High-fiber foods will cause diarrhea. The client will need to
empty the ostomy pouch when it is one-third to one-half full. Water and a simple squirt bottle can be
used to remove effluence from the pouch and reduce odors.
A client status post-cholecystectomy 3 days is being prepared to be discharged home. Which client
finding is the best indication to the practical nurse that postoperative nursing interventions have
prevented respiratory complications?
1 M| MP M a M g M e
,
