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.
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.
