Redirect the client's acting out behavior by asking him to perform a unit
task.
A group of nursing students is touring an in-patient psychiatric unit when
a male client who is in a manic state shouts, "Want to see a crazy person?"
and begins
to jump up and down, flap his arms, and cluck like a chicken. Which action
is best for the nurse to take?
A Direct the students to continue the tour without responding to the
client's behavior.
B Medicate the client with a PRN prescription for an antianxiety agent.
C Restrict the client to his room until he can control his behaviors.
D Redirect the client's acting out behavior by asking him to perform a unit
task.
Nausea with projectile vomiting.
An adult male client is brought to the emergency department (ED) by
ambulance following a motorcycle collision. He was not wearing a helmet and
presents with periorbital bruising and bloody drainage from both ears.
Which assessment finding warrants immediate intervention by the nurse?
A Rebound abdominal tenderness.
B Diminished bilateral breath sounds.
C Nausea with projectile vomiting.
D Rib pain with deep inspiration.
C. A change in urine color to dark red often occurs while taking this drug.
D. An upset stomach may occur as a side effect of this medication.
A client diagnosed with Parkinson's disease receives a prescription for
carbidopa-levodopa, controlled release (CR) 25/100 mg PO daily each morning.
Which information should the nurse include in the client's teaching plan?
Select all that apply.
A Parkinson symptoms should diminish within one week.
B Avoid sunlight and wear sunglasses while outdoors.
,C A change in urine color to dark red often occurs while taking this drug.
D An upset stomach may occur as a side effect of this medication.
E The medication should only be taken during a meal.
25 gtt/min
The healthcare provider (HCP) prescribes 500 mL of 0.45% normal saline with
100 units regular insulin to infuse at 15 units/hour. The drop factor is 20
gtt/mL.
The nurse should regulate the IV to deliver how many gtt/minute? (Enter
numerical value only.)
Focus on small achievable tasks, not taxing problems.
A client with generalized anxiety disorder does not want to communicate
with friends, smokes 2 to 3 packages of cigarettes a day, and describes
difficulty concentrating at work. Which coping strategy should the nurse
include in the plan of care (POC)?
A Focus on small achievable tasks, not taxing problems.
B Concentrate on and ventilate emotions when distressed.
C Relax and reduce the amount of effort to solve the problem.
D Analyze past hurts and resentments to identify the source.
A. Raise the head of the bed to 30° keeping head and neck in neutral
alignment.
The nurse is caring for a client who reports sudden right sided numbness
and weakness of the arm and leg. The nurse also observes a distinct right
sided facial droop. After reporting the findings to the healthcare provider
(HCP), the nurse receives several prescriptions for the client, including a
STAT computerized tomography (CT) scan of the head. Which action should the
nurse take first?
• A Raise the head of the bed to 30° keeping head and neck in neutral
alignment.
• B Start two large bore peripheral IV (PIV) catheters and review inclusion
criteria for IV fibrinolytic therapy.
,• C Administer aspirin to prevent further clot formation and platelet
clumping.
• D Begin continuous observation for transient episodes of neurologic
dysfunction.
Daily use of spironolactone for hypertension.
An older adult client is admitted with pneumonia, and the healthcare
provider (HCP) prescribes penicillinG potassium IV. Which assessment
finding increases the risk of adverse reactions in this client?
A Previous treatment with penicillin for pneumonia.
B Daily use of spironolactone for hypertension.
C Documented allergy to sulfonamides.
D Sputum culture results of Streptococcus pneumoniae.
Divide the medication into two injections with volumes under 1 mL.
The nurse is preparing to administer 1.6 mL of medication IM to a 4-month-
old infant. Which action should the nurse include?
A Select a 22 gauge 1 1/2 inch (3.8 cm) needle for the intramuscular
injection.
B Administer into the deltoid muscle while the parent holds the infant
securely.
C Use a quick dart like motion to inject into the dorsogluteal site
D Divide the medication into two injections with volumes under 1 mL.
1.3 mL
An infant who weighs 22 Ibs. receives a prescription for amoxicillin 20
mg/kg/day PO in divided doses every 8 hours. The bottle is labeled,
"Amoxicillin for Oral Suspension, USP 250 mg per 5 mL." How many mL should
the nurse administer with each dose? (Enter numerical value only. If
rounding is necessary, round to the nearest tenth.)
A Decrease the rate at which the feeding is given.
, A client who is homebound and is receiving continuous feedings through a
gastrostomy tube reports experiencing frequent diarrhea. Which instructions
should the nurse provide
A Decrease the rate at which the feeding is given.
B Do not allow the feeding to sit at room temperature.
C Increase the concentration of the teedings.
D Elevate the head of the bed to ninety degrees.
B. Wash the residual limb with soap and water
C. Use a residual limb shrinker
D. Inspect skin for redness.
The nurse is preparing a client who had a below-the-knee (BKA) amputation
for discharge to home. Which recommendations) should the nurse provide this
client? Select all that apply.
A Avoid range of motion exercises
B Wash the residual limb with soap and water
C Use a residual limb shrinker
D Inspect skin for redness.
E Apply alcohol to the residual limb after bathing
Report the eye pain to the surgeon.
Following laser trabeculoplasty surgery for open-angle glaucoma, the client
reports acute pain deep within the eye. Which action should the nurse take?
• A Report the eye pain to the surgeon.
• B Administer an antiemetic to prevent vomiting.
• C Apply bilateral eye shields to reduce photosensitivity.
• D Begin postoperative prophylactic antibiotics.
4. Note date and time of the behavior.
2. Discuss the issue privately with the UAP
3. Plan for scheduled break times
1. Evaluate the UAP for signs of improvement.
task.
A group of nursing students is touring an in-patient psychiatric unit when
a male client who is in a manic state shouts, "Want to see a crazy person?"
and begins
to jump up and down, flap his arms, and cluck like a chicken. Which action
is best for the nurse to take?
A Direct the students to continue the tour without responding to the
client's behavior.
B Medicate the client with a PRN prescription for an antianxiety agent.
C Restrict the client to his room until he can control his behaviors.
D Redirect the client's acting out behavior by asking him to perform a unit
task.
Nausea with projectile vomiting.
An adult male client is brought to the emergency department (ED) by
ambulance following a motorcycle collision. He was not wearing a helmet and
presents with periorbital bruising and bloody drainage from both ears.
Which assessment finding warrants immediate intervention by the nurse?
A Rebound abdominal tenderness.
B Diminished bilateral breath sounds.
C Nausea with projectile vomiting.
D Rib pain with deep inspiration.
C. A change in urine color to dark red often occurs while taking this drug.
D. An upset stomach may occur as a side effect of this medication.
A client diagnosed with Parkinson's disease receives a prescription for
carbidopa-levodopa, controlled release (CR) 25/100 mg PO daily each morning.
Which information should the nurse include in the client's teaching plan?
Select all that apply.
A Parkinson symptoms should diminish within one week.
B Avoid sunlight and wear sunglasses while outdoors.
,C A change in urine color to dark red often occurs while taking this drug.
D An upset stomach may occur as a side effect of this medication.
E The medication should only be taken during a meal.
25 gtt/min
The healthcare provider (HCP) prescribes 500 mL of 0.45% normal saline with
100 units regular insulin to infuse at 15 units/hour. The drop factor is 20
gtt/mL.
The nurse should regulate the IV to deliver how many gtt/minute? (Enter
numerical value only.)
Focus on small achievable tasks, not taxing problems.
A client with generalized anxiety disorder does not want to communicate
with friends, smokes 2 to 3 packages of cigarettes a day, and describes
difficulty concentrating at work. Which coping strategy should the nurse
include in the plan of care (POC)?
A Focus on small achievable tasks, not taxing problems.
B Concentrate on and ventilate emotions when distressed.
C Relax and reduce the amount of effort to solve the problem.
D Analyze past hurts and resentments to identify the source.
A. Raise the head of the bed to 30° keeping head and neck in neutral
alignment.
The nurse is caring for a client who reports sudden right sided numbness
and weakness of the arm and leg. The nurse also observes a distinct right
sided facial droop. After reporting the findings to the healthcare provider
(HCP), the nurse receives several prescriptions for the client, including a
STAT computerized tomography (CT) scan of the head. Which action should the
nurse take first?
• A Raise the head of the bed to 30° keeping head and neck in neutral
alignment.
• B Start two large bore peripheral IV (PIV) catheters and review inclusion
criteria for IV fibrinolytic therapy.
,• C Administer aspirin to prevent further clot formation and platelet
clumping.
• D Begin continuous observation for transient episodes of neurologic
dysfunction.
Daily use of spironolactone for hypertension.
An older adult client is admitted with pneumonia, and the healthcare
provider (HCP) prescribes penicillinG potassium IV. Which assessment
finding increases the risk of adverse reactions in this client?
A Previous treatment with penicillin for pneumonia.
B Daily use of spironolactone for hypertension.
C Documented allergy to sulfonamides.
D Sputum culture results of Streptococcus pneumoniae.
Divide the medication into two injections with volumes under 1 mL.
The nurse is preparing to administer 1.6 mL of medication IM to a 4-month-
old infant. Which action should the nurse include?
A Select a 22 gauge 1 1/2 inch (3.8 cm) needle for the intramuscular
injection.
B Administer into the deltoid muscle while the parent holds the infant
securely.
C Use a quick dart like motion to inject into the dorsogluteal site
D Divide the medication into two injections with volumes under 1 mL.
1.3 mL
An infant who weighs 22 Ibs. receives a prescription for amoxicillin 20
mg/kg/day PO in divided doses every 8 hours. The bottle is labeled,
"Amoxicillin for Oral Suspension, USP 250 mg per 5 mL." How many mL should
the nurse administer with each dose? (Enter numerical value only. If
rounding is necessary, round to the nearest tenth.)
A Decrease the rate at which the feeding is given.
, A client who is homebound and is receiving continuous feedings through a
gastrostomy tube reports experiencing frequent diarrhea. Which instructions
should the nurse provide
A Decrease the rate at which the feeding is given.
B Do not allow the feeding to sit at room temperature.
C Increase the concentration of the teedings.
D Elevate the head of the bed to ninety degrees.
B. Wash the residual limb with soap and water
C. Use a residual limb shrinker
D. Inspect skin for redness.
The nurse is preparing a client who had a below-the-knee (BKA) amputation
for discharge to home. Which recommendations) should the nurse provide this
client? Select all that apply.
A Avoid range of motion exercises
B Wash the residual limb with soap and water
C Use a residual limb shrinker
D Inspect skin for redness.
E Apply alcohol to the residual limb after bathing
Report the eye pain to the surgeon.
Following laser trabeculoplasty surgery for open-angle glaucoma, the client
reports acute pain deep within the eye. Which action should the nurse take?
• A Report the eye pain to the surgeon.
• B Administer an antiemetic to prevent vomiting.
• C Apply bilateral eye shields to reduce photosensitivity.
• D Begin postoperative prophylactic antibiotics.
4. Note date and time of the behavior.
2. Discuss the issue privately with the UAP
3. Plan for scheduled break times
1. Evaluate the UAP for signs of improvement.
