An elderly client with a fractured left hip is on strict bedrest. Which nursing
measure is essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position. - To avoid
shearing forces when repositioning, the client should be lifted gently across
a surface (D). Reddened areas should not be massaged (A) since this may
increase the damage to already traumatized skin. To control pain and muscle
spasms, active range of motion (B) may be limited on the affected leg. The
position described in (C) is contraindicated for a client with a fractured left
hip.
Correct Answer: D
The nurse is administering medications through a nasogastric tube (NGT)
which is connected to suction. After ensuring correct tube placement, what
action should the nurse take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water. - The NGT should be
flushed before, after and in between each medication administered (B). Once
all medications are administered, the NGT should be clamped for 20 minutes
(A). (C and D) may be implemented only after the tubing has been flushed.
Correct Answer: B
A client who is in hospice care complains of increasing amounts of pain. The
healthcare provider prescribes an analgesic every four hours as needed.
Which action should the nurse implement?
A. Give an around-the-clock schedule for administration of analgesics.
,B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities. -
The most effective management of pain is achieved using an around-the-
clock schedule that provides analgesic medications on a regular basis (A)
and in a timely manner. Analgesics are less effective if pain persists until it
is severe, so an analgesic medication should be administered before the
client's pain peaks (B). Providing comfort is a priority for the client who is
dying, but sedation that impairs the client's ability to interact and experience
the time before life ends should be minimized (C). Offering a medication-free
period allows the serum drug level to fall, which is not an effective method to
manage chronic pain (D).
Correct Answer: A
When assessing a client with wrist restraints, the nurse observes that the
fingers on the right hand are blue. What action should the nurse implement
first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse. - The priority nursing action is to restore
circulation by loosening the restraint (A), because blue fingers (cyanosis)
indicates decreased circulation. (C and D) are also important nursing
interventions, but do not have the priority of (A). Pulse oximetry (B) measures
the saturation of hemoglobin with oxygen and is not indicated in situations
where the cyanosis is related to mechanical compression (the restraints).
Correct Answer: A
The nurse is assessing the nutritional status of several clients. Which client
has the greatest nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
,B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer. - A lactating woman (B)
has the greatest need for additional protein intake. (A, C, and D) are all
conditions that require protein, but do not have the increased metabolic
protein demands of lactation.
Correct Answer: B
A client is in the radiology department at 0900 when the prescription
levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The
client returns to the unit at 1300. What is the best intervention for the nurse
to implement?
A. Contact the healthcare provider and complete a medication variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the
morning.
C. Notify the charge nurse and complete an incident report to explain the
missed dose.
D. Give the missed dose at 1300 and change the schedule to administer daily
at 1300. - To ensure that a therapeutic level of medication is maintained, the
nurse should administer the missed dose as soon as possible, and revise the
administration schedule accordingly to prevent dangerously increasing the
level of the medication in the bloodstream (D). The nurse should document
the reason for the late dose, but (A and C) are not warranted. (B) could result
in increased blood levels of the drug.
Correct Answer: D
While instructing a male client's wife in the performance of passive range-of-
motion exercises to his contracted shoulder, the nurse observes that she is
holding his arm above and below the elbow. What nursing action should the
nurse implement?
A. Acknowledge that she is supporting the arm correctly.
, B. Encourage her to keep the joint covered to maintain warmth.
C. Reinforce the need to grip directly under the joint for better support.
D. Instruct her to grip directly over the joint for better motion. - The wife is
performing the passive ROM correctly, therefore the nurse should
acknowledge this fact (A). The joint that is being exercised should be
uncovered (B) while the rest of the body should remain covered for warmth
and privacy. (C and D) do not provide adequate support to the joint while still
allowing for joint movement.
Correct Answer: A
What is the most important reason for starting intravenous infusions in the
upper extremities rather than the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a thrombosis.
C. A cannulated extremity is more difficult to move when the leg or foot is
used.
D. Veins are located deep in the feet and ankles, resulting in a more painful
procedure. - Venous return is usually better in the upper extremities.
Cannulation of the veins in the lower extremities increases the risk of
thrombus formation (B) which, if dislodged, could be life-threatening.
Superficial veins are often very easy (A) to find in the feet and legs. Handling
a leg or foot with an IV (C) is probably not any more difficult than handling an
arm or hand. Even if the nurse did believe moving a cannulated leg was more
difficult, this is not the most important reason for using the upper
extremities. Pain (D) is not a consideration.
Correct Answer: B
The nurse observes an unlicensed assistive personnel (UAP) taking a client's
blood pressure with a cuff that is too small, but the blood pressure reading
obtained is within the client's usual range. What action is most important for
the nurse to implement?
measure is essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position. - To avoid
shearing forces when repositioning, the client should be lifted gently across
a surface (D). Reddened areas should not be massaged (A) since this may
increase the damage to already traumatized skin. To control pain and muscle
spasms, active range of motion (B) may be limited on the affected leg. The
position described in (C) is contraindicated for a client with a fractured left
hip.
Correct Answer: D
The nurse is administering medications through a nasogastric tube (NGT)
which is connected to suction. After ensuring correct tube placement, what
action should the nurse take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water. - The NGT should be
flushed before, after and in between each medication administered (B). Once
all medications are administered, the NGT should be clamped for 20 minutes
(A). (C and D) may be implemented only after the tubing has been flushed.
Correct Answer: B
A client who is in hospice care complains of increasing amounts of pain. The
healthcare provider prescribes an analgesic every four hours as needed.
Which action should the nurse implement?
A. Give an around-the-clock schedule for administration of analgesics.
,B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities. -
The most effective management of pain is achieved using an around-the-
clock schedule that provides analgesic medications on a regular basis (A)
and in a timely manner. Analgesics are less effective if pain persists until it
is severe, so an analgesic medication should be administered before the
client's pain peaks (B). Providing comfort is a priority for the client who is
dying, but sedation that impairs the client's ability to interact and experience
the time before life ends should be minimized (C). Offering a medication-free
period allows the serum drug level to fall, which is not an effective method to
manage chronic pain (D).
Correct Answer: A
When assessing a client with wrist restraints, the nurse observes that the
fingers on the right hand are blue. What action should the nurse implement
first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse. - The priority nursing action is to restore
circulation by loosening the restraint (A), because blue fingers (cyanosis)
indicates decreased circulation. (C and D) are also important nursing
interventions, but do not have the priority of (A). Pulse oximetry (B) measures
the saturation of hemoglobin with oxygen and is not indicated in situations
where the cyanosis is related to mechanical compression (the restraints).
Correct Answer: A
The nurse is assessing the nutritional status of several clients. Which client
has the greatest nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
,B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer. - A lactating woman (B)
has the greatest need for additional protein intake. (A, C, and D) are all
conditions that require protein, but do not have the increased metabolic
protein demands of lactation.
Correct Answer: B
A client is in the radiology department at 0900 when the prescription
levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The
client returns to the unit at 1300. What is the best intervention for the nurse
to implement?
A. Contact the healthcare provider and complete a medication variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the
morning.
C. Notify the charge nurse and complete an incident report to explain the
missed dose.
D. Give the missed dose at 1300 and change the schedule to administer daily
at 1300. - To ensure that a therapeutic level of medication is maintained, the
nurse should administer the missed dose as soon as possible, and revise the
administration schedule accordingly to prevent dangerously increasing the
level of the medication in the bloodstream (D). The nurse should document
the reason for the late dose, but (A and C) are not warranted. (B) could result
in increased blood levels of the drug.
Correct Answer: D
While instructing a male client's wife in the performance of passive range-of-
motion exercises to his contracted shoulder, the nurse observes that she is
holding his arm above and below the elbow. What nursing action should the
nurse implement?
A. Acknowledge that she is supporting the arm correctly.
, B. Encourage her to keep the joint covered to maintain warmth.
C. Reinforce the need to grip directly under the joint for better support.
D. Instruct her to grip directly over the joint for better motion. - The wife is
performing the passive ROM correctly, therefore the nurse should
acknowledge this fact (A). The joint that is being exercised should be
uncovered (B) while the rest of the body should remain covered for warmth
and privacy. (C and D) do not provide adequate support to the joint while still
allowing for joint movement.
Correct Answer: A
What is the most important reason for starting intravenous infusions in the
upper extremities rather than the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a thrombosis.
C. A cannulated extremity is more difficult to move when the leg or foot is
used.
D. Veins are located deep in the feet and ankles, resulting in a more painful
procedure. - Venous return is usually better in the upper extremities.
Cannulation of the veins in the lower extremities increases the risk of
thrombus formation (B) which, if dislodged, could be life-threatening.
Superficial veins are often very easy (A) to find in the feet and legs. Handling
a leg or foot with an IV (C) is probably not any more difficult than handling an
arm or hand. Even if the nurse did believe moving a cannulated leg was more
difficult, this is not the most important reason for using the upper
extremities. Pain (D) is not a consideration.
Correct Answer: B
The nurse observes an unlicensed assistive personnel (UAP) taking a client's
blood pressure with a cuff that is too small, but the blood pressure reading
obtained is within the client's usual range. What action is most important for
the nurse to implement?
