1. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child?
Review Information: The correct answer is D: "I
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1. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child?
Review Information: The correct answer is D: "I have the four year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." The infant seat is to be placed on the rear seat. Small children and infants are not to be left unsupervised. Infants are to be placed on their "back when they go back" to sleep or are lying in a crib. A 4 year-old could assist with the care of an infant with proper supervision. This enhances bonding with the infant and the
developmental needs of the preschooler to "help" and not feel left out.
2. Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take?
Review Information: The correct answer is B: Give information about advance directives
For each admission, nurses should request a copy of the current advance directive. If there is none, the nurse must offer information about what an advance directive implies. It is then the client’s choice to sign it. In option 1 just recording the information is not sufficient. In option 3 the nurse should not assume that the client has been informed of choices for emergency care. In option 4 this represents an inappropriate delegation approach.
3. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to
Review Information: The correct answer is D: Call the provider for clarification Relying on anyone else''s interpretation is very risky. When in doubt, check it out with the person who wrote the illegible order. Order entry systems help to minimize this problem.
7. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:
Review Information: The correct answer is D: open the client''s airway According to the ABCs of CPR the first step in rescuing an unresponsive victim after checking responsiveness and calling for help is to open the victims airway. The airway must be opened appropriately before the need for rescue breaths can be determined. The pulse is assessed, after breathing is evaluated. The need for abdominal thrusts is determined by inability to achieve chest rise when ventilation is attempted.
8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?
Review Information: The correct answer is D: Ausculate the lungs
All of the options would be part of the evaluation for the effects of the large amount of fluid in a short period of time. However the worst result is heart failure with lung congestion so the auscultation of the lungs is the priority action. The sequence of actions would be 4 1 3 2.
9. Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
Review Information: The correct answer is B: Administer epinephrine 1:1000 as ordered .All the answers are correct given the circumstances. The correct sequence of care is to administer the epinephrine, then maintain airway. In the early stages of anaphylaxis, when the patient has not lost consciousness and is normatensive, administering the epinephrine and then applying the oxygen, watching for hypotension and shock are later responses. The prevention of a severe crisis is maintained by using diphenhydramine.
4. Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category?
Review Information: The correct answer is C: 72 year-old recovering from surgery after a hip replacement 2 hours ago
Look for the client who is in the least stable condition. The client who returned from surgery 2 hours ago is at risk for hemorrhage and should be seen first. The 16 year-old should be seen next because it is still the first post-op day. The 75 year-old in skin traction should be seen next. The client who can safely be seen last is the 20 year-old who is 2 weeks post-injury.
10. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?
Review Information: The correct answer is B: A toddler with severe deep abrasions over 98% of the body .This child has the least chance of survival. Severe deep abrasions are to be thought of as second and third degree burns. The child has great risk of shock and infection combined.
5. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse’s best action is to
Review Information: The correct answer is C: notify the admissions office and wait to apply the bracelet
The Admissions Office has the responsibility to verify the client’s identity and keep all the records in the system consistent. Making the changes puts the client at risk for misidentification. Using an incorrect identification bracelet is unsafe. Making a new bracelet on the unit is not appropriate.
6. The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken?
Review Information: The correct answer is B: That was done correctly. Did you have any problems with the insertion?
Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication. After a short time it will not hurt the client to turn in any manner. The suppository should be somewhat melted after 10 to 15 minutes. The other responses are incorrect since no data is in the stem to support such comments.
11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care?
Review Information: The correct answer is C: contact precautions
The resistant bacteria remain alive for up to 3 days post death. Therefore, contact precautions must still be implemented. Also label the body so that the funeral home staff can protect themselves as well. Gown and gloves are required.
12. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching?
Review Information: The correct answer is B: clean the meatus, begin voiding, then catch urine stream
A clean catch urine is difficult to obtain and requires clear directions. Instructing the client to carefully clean the meatus, then void naturally with a steady stream prevents surface bacteria from contaminating the urine specimen. As starting and stopping flow can be difficult, once the client begins voiding it''s best to just slip the container into the stream. Other responses are not correct technique.
13. The provider orders Lanoxin (digoxin) 0.125 mg po and furosomide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily?
Review Information: The correct answer is B: watermelon Watermelon is high in potassium and will replace any potassium lost by the diuretic. The other foods are not high in potassium.
14. A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take?
An elderly client who had a myocardial infarction a week ago - UAP Review Information: The correct answer is A: An admission at the change of shifts with atrial fibrillation and heart failure - PN
The care for a new admissions should be performed by an RN. Since the client was admitted at the change of shifts, the stability of the client would not have been established. The charge nurse should take this client. The PN could monitor the IV fluids in option C. Tasks that do not require independent judgment should be delegated. The nurse may delegate the care for a stable client to a UAP.
19. A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment?
Review Information: The correct answer is B: Restlessness and increased mucus production
This infant could be experiencing gastroesophageal reflux, or could be allergic to the formula. Restlessness, irritability and increased mucus production can develop if an allergy is present. Soy based formula is often recommended.
20. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis?
Review Information: The correct answer is C: Immediately wash the hands with vigor
The immediate action of vigorously washing will help remove possible contamination. Then the sequence would then be options 4, 1, 2.
15. As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do?
Review Information: The correct answer is C: "Clothes are becoming tighter across her abdomen."
One of the most common signs of neuroblastoma is increased abdominal girth. The parents'' report that clothing is tight is significant, and should be followed by additional assessments.
21. A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse?
Review Information: The correct answer is D: Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.”
This action is a direct threat to the client if the medication enters into the blood stream instead of the muscle. The purpose of aspiration with IM injections is to prevent the injection of the drug directly into the blood stream. Option 4 protects the client and is the most professional.
16. A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
Review Information: The correct answer is D: Proceed with the triage process in the same manner as any adult client
Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this client, who is married, has the legal capacity of an adult.
22. A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?
Review Information: The correct answer is B: Glascow Coma Scale 8, respirations regular
The Glascow Coma Scale provides a standard reference for assessing or monitoring level of consciousness. Any score less than 13 indicates a neurological impairment. Using the term comatose provides too much room for interpretation and is not very precise.
17. A client enters the emergency department unconscious via ambulance from the client’s work place. What document should be given priority to guide the direction of care for this client?
Review Information: The correct answer is B: Report output of less than 30 ml/hr
When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported. Because the RN is responsible for all care-related decisions, only implementation tasks should be assigned because they do not require independent judgment.
23. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease?
Review Information: The correct answer is C: A notarized original of advance directives brought in by the partner
This document specifies the client''s wishes.
18. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager?
Review Information: The correct answer is B: Strep throat went through all the children at the day care last month.
Evidence supports a strong relationship between infection with Group A streptococci and subsequent rheumatic fever (usually within 2 to 6 weeks). Therefore, the history of playmates recovering from strep throat would indicate that the child diagnosed with rheumatic fever most likely also had strep throat. Sometimes, such an infection has no clinical symptoms.
24. A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to
30. Which statement best describes time management strategies applied to the role of a nurse manager?
Review Information: The correct answer is A: Discuss the feeling of reluctance with an objective peer or supervisor
The nurse who experiences stress in the therapeutic relationship can gain objectivity through supervision. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse- client relationship.
25. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse’s action
Review Information: The correct answer is C: Set daily goals with a prioritization of the work
Time management strategies include setting goals and prioritization . This is similar to time management of direct care for clients
31. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these?
Review Information: The correct answer is A: May result in charges of unlawful seclusion and restraint
Seclusion should only be used when there is an immediate threat of violence or threatening behavior to the staff, the other clients, or the client upon himself.
26. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority?
Review Information: The correct answer is D: Abdominal mass and weakness Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline, weakness, pallor, anorexia, weight loss and irritability.
32. A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching?
Review Information: The correct answer is A: Pain related to ischemia
Pain is related to ischemia, and relief of pain will decrease myocardial oxygen demands, reduce blood pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system and increased preload, further increasing myocardial demands.
27. The provisions of the law for the Americans with Disabilities Act require nurse managers to
Review Information: The correct answer is A: "I will only have to wear this for 6 months."
The brace must be worn long-term, during periods of growth, usually for 1 to 2 years. It is used to correct curvature of the spine.
33. The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self- scheduling knowing that this method will
Review Information: The correct answer is B: Provide reasonable accommodations for disabled individuals
The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant’s ability to perform the job and not discriminate on the basis of a disability.
Employers also must make "reasonable accommodations."
28. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance?
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