(A) provides the best schedule, because QID means four times per day. (B, C, and D) provide incorrect dosages.
Correct Answer: A - ANSWER A medication is prescribed to be given QID. What schedule should the nurse use to
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(A) provides the best schedule, because QID means four times per day. (B, C, and D) provide incorrect dosages.
Correct Answer: A - ANSWER A medication is prescribed to be given QID. What schedule should the nurse use to administer this prescription?
A. 0800, 1200, 1600, 2000.
B. 800.
C. Every other day at 0800.
D. 0800, 1200, 1600, 2000, 0000, 0400.
(C) is an open-ended question that encourages the client to discuss personal feelings. (A) devalues the client and hinders further communication. Acting defensively and asking why questions such as (B) are likely to elicit more anger and block communication. By deferring to the client advocate (D), the nurse fails to even address the client's feelings of anger and exasperation.
Correct Answer: C - ANSWER When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse respond?
A. There is no reason to be so angry.
B. Why do I need to leave your room?
C. What is concerning you this morning?
D. Let me call the client advocate for you.
(D) will help to move and drain respiratory secretions and prevent pneumonia from occurring, so this intervention has the highest priority. Older adults often have an increased BP, and a PRN antihypertensive medication is usually prescribed for a BP over 140 systolic and 90 diastolic (A). Older adults often run a lower temperature, particularly in the morning, and (B) does not have the priority of (D). Even though the client has adequate output, (C) might be encouraged because the urine is concentrated, but this intervention does not have the priority of (D).
Correct Answer: D - ANSWER The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8° F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement?
A. Administer a PRN antihypertensive prescription.
B. Provide the client with an additional blanket.
C. Encourage additional fluid intake.
D. Turn the client q2h.
A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities. The mother's assistance (C) can provide a stabilizing presence to help soothe the preschooler, who may perceive the invasive procedure as mutilating. To preserve the child's sense of security associated with the hospital room, it is best to perform difficult or painful procedures in another area (A). (B) may be necessary to prevent injury if the child is unable to cooperate with the mother's coaxing. (D) is best done before going to the treatment room when the child feels less threatened.
Correct Answer: C - ANSWER As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the treatment room, he cries continuously. What intervention should the nurse implement?
A. Take the child back to his room.
B. Recruit others to restrain the child.
C. Ask the mother to be present to soothe the child.
D. Show the child how to manipulate the equipment.
A 20-pound box is safely lifted by bending the knees (D), holding the box close to the center of gravity, and extending the legs using the quadriceps muscles. (A and B) might be helpful, but the charge nurse should use this opportunity to reinforce proper body mechanics techniques. Pushing the box against the wall (C) does not assist with lifting.
Correct Answer: D - ANSWER The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20-pound box of medical supplies off the treatment room floor. What instruction should the charge nurse provide to the UAP?
A. Ask another staff member for assistance.
B. Request that supplies are delivered in smaller containers.
C. Push the box against the wall to provide support while lifting.
D. Bend at the knees when lifting heavy objects.
A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle (D). A client using a bed cradle may still be able to ambulate independently (A) and does not require raised side rails (B). (C) causes the nurse to use poor body mechanics.
Correct Answer: D - ANSWER When making the bed of a client who needs a bed cradle, which action should the nurse include?
A. Teach the client to call for help before getting out of bed.
B. Keep both the upper and lower side rails in a raised position.
C. Keep the bed in the lowest position while changing the sheets.
D. Drape the top sheet and covers loosely over the bed cradle.
A cassette pump (B) should be used to accurately deliver large volumes of fluid over longer periods of time with extreme precise, such as ml/hour. A syringe pump (A) is accurate for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid volume replacement. Volumetric (C) and nonvolumetric (D) controllers count drops/minute to administer fluid volume and are inherently inaccurate because of variation in drop size.
Correct Answer: B - ANSWER The nurse is preparing to give a client with dehydration IV fluids delivered at a continuous rate of 175 ml/hour. Which infusion device should the nurse use?
A. Portable syringe pump.
B. Cassette infusion pump.
C. Volumetric controller.
D. Nonvolumetric controller.
A client who can stand can safely be assisted to pivot and transfer with the use of a transfer belt (D). A mechanical lift (A) is usually used for a client who is obese, unable to be weight-bearing, and who is unable to assist. Roller boards (B) placed under a sheet are used to facilitate the transfer of a recumbent client who is being transferred to and from a stretcher. Lifting a client (C) out of bed places the client and nurses at risk for injury and should only be implemented by skilled lift teams.
Correct Answer: D - ANSWER An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair?
A. Use a mechanical lift to transfer from the bed to a chair.
B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair.
C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three.
D. Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed.
A client with chronic pain is more likely to have adapted physiologically to vital sign changes, localization or intensity, so pain assessment should focus on any interference with daily activities (D), sleep, relationships with others, physical activity, and emotional well-being. Exacerbation of acute symptoms, such as pain distribution, patterns, intensity, and descriptors illicit specific assessment findings, whereas (A, B, and C) are limiting, closed-end questions, and can be answered with a yes, no, or a number.
Correct Answer: D - ANSWER To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain?
A. Can you describe where your pain is the most severe?
B. What is your pain intensity on a scale of 1 to 10?
C. Is your pain best described as aching, throbbing, or sharp?
D. Which activities during a routine day are impacted by your pain?
A client's dietary habits should be determined first by the client's dietary recall (B) before suggesting protein sources or supplements (A and C) as options in the client's diet. Although grains and legumes (D) contain incomplete proteins that reduces the essential amino acid pools inside the cells, the client's cultural preferences should be illicited after confirming the client's dietary history.
Correct Answer: B - ANSWER A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first?
A. Amount of liquid protein supplements consumed daily.
B. Foods and liquids consumed during the past 24 hours.
C. Usual weekly intake of milk products and red meats.
D. Grains and legume combinations used by the client.
A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables, beans, and vegetarian soups, and the client needs essential amino acids to provide complete proteins to heal the infected wound. Although a macrobiotic diet contains no source of animal protein, essential amino acids should be obtained by combining plant (incomplete) proteins to provide complete (all essential amino acids) proteins (B) for anabolic processes. (A, C, and D) do not provide the client with food choices consistent with a macrobiotic diet and protein needs.
Correct Answer: B - ANSWER A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu?
A. Low fat and low sodium foods.
B. Combination of plant proteins to provide essential amino acids.
C. Limited complex carbohydrates and fiber.
D. Increased amount of vitamin C and beta carotene rich foods.
A positive Chvostek's sign is an indication of hypocalcemia, so the client should be assessed for the subjective symptoms of hypocalcemia, such as numbness or tingling of the hands (B) or feet. (A and C) are unrelated assessment data. (D) is contraindicated because the client is hypocalcemic and needs additional dietary calcium.
Correct Answer: B - ANSWER A client is demonstrating a positive Chvostek's sign. What action should the nurse take?
A. Observe the client's pupil siz
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