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 o
...
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. Ans- 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. Ans- 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. Ans- 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. Ans- 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. Ans- 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. Ans- 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. Ans- 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. Ans- 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?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure. Ans- The most important action is
to ensure that an accurate BP reading is obtained. The nurse should reassess the BP with the correct size
cuff (B). Reassessment should not be postponed (A). Though (C and D) are likely indicated, these actions
do not have the priority of (B).
Correct Answer: B
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy
diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how
many ml/hr should the infusion pump be set to deliver the secondary infusion? Ans- The infusion rate is
calculated as a ratio proportion problem, i.e., 50 ml/ 20 min : x ml/ 60 min. Multiply extremes and
means 50 × 60 /20x 1= 300/20=150
Correct Answer: 150
Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels
warm enough. What is the best response by the nurse?
A. That means you have derived the maximum benefit, and the heat can be removed.
B. Your blood vessels are becoming dilated and removing the heat from the site.
C. We will increase the temperature 5 degrees when the pad no longer feels warm.
D. The body's receptors adapt over time as they are exposed to heat. Ans- (D) describes thermal
adaptation, which occurs 20 to 30 minutes after heat application. (A and B) provide false information.
(C) is not based on a knowledge of physiology and is an unsafe action that may harm the client.
Correct Answer: D
The nurse is instructing a client with high cholesterol about diet and life style modification. What
comment from the client indicates that the teaching has been effective?
A. If I exercise at least two times weekly for one hour, I will lower my cholesterol.
B. I need to avoid eating proteins, including red meat.
C. I will limit my intake of beef to 4 ounces per week.
D. My blood level of low density lipoproteins needs to increase. Ans- Limiting saturated fat from animal
food sources to no more than 4 ounces per week (C) is an important diet modification for lowering
cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at
least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower
cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings).
The low density lipoproteins (D) need to decrease rather than increase.
Correct Answer: C
The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to
transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the
correct transfer procedure for this client?
A. Place the chair at a right angle to the bed on the client's left side before moving.
B. Assist the client to a standing position, then place the right hand on the armrest.
C. Have the client place the left foot next to the chair and pivot to the left before sitting.
D. Move the chair parallel to the right side of the bed, and stand the client on the right foot. Ans- (D)
uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest
approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body
mechanics by the caregiver.
Correct Answer: D
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a
soap suds enema. Which instruction should the nurse provide the UAP?
A. Position the client on the right side of the bed in reverse Trendelenburg.
B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
C. Reposition in a Sim's position with the client's weight on the anterior ilium.
D. Raise the side rails on both sides of the bed and elevate the bed to waist level. Ans- The left sided
Sims' position allows the enema solution to follow the anatomical course of the intestines and allows
the best overall results, so the UAP should reposition the client in the Sims' position, which distributes
the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the
client is positioned.
Correct Answer: C
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse
have for planning care in terms of the client's beliefs?
A. Autopsy of the body is prohibited.
B. Blood transfusions are forbidden.
C. Alcohol use in any form is not allowed.
D. A vegetarian diet must be followed. Ans- Blood transfusions are forbidden (B) in the Jehovah's
Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of these sects
are vegetarian (D), but the direct impact on nursing care is (B).
Correct Answer: B
The nurse observes that a male client has removed the covering from an ice pack applied to his knee.
What action should the nurse take first?
A. Observe the appearance of the skin under the ice pack.
B. Instruct the client regarding the need for the covering.
C. Reapply the covering after filling with fresh ice.
D. Ask the client how long the ice was applied to the skin. Ans- The first action taken by the nurse should
be to assess the skin for any possible thermal injury (A). If no injury to the skin has occurred, the nurse
can take the other actions (B, C, and D) as needed.
Correct Answer: A
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5
mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per
minute should the client receive?
A. 31 gtt/min.
B. 62 gtt/min.
C. 93 gtt/min.
D. 124 gtt/min. Ans- (D) is the correct calculation: Convert lbs to kg: 182/2.2 = 82.73 kg. Determine the
dosage for this client: 5 mcg × 82.73 = 413.65 mcg/min. Determine how many mcg are contained in 1 ml:
250/50,000 mcg = 200 mcg per ml. The client is to receive 413.65 mcg/min, and there are 200 mcg/ml;
so the client is to receive 2.07ml per minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28
gtt/min (D) OR, using dimensional analysis: gtt/min = 60 gtt/ml X 250 ml/50 mg X 1 mg/1,000 mcg X 5
mcg/kg/min X 1 kg/2.2 lbs X 182 lbs.
Correct Answer: D
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous
pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine
now. What action is best for the nurse to take?
A. Record the coughing incident. No further action is required at this time.
B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. Ans- Coughing,
vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward
into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid
withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline
(intestine) values is a more sensitive method for these tubes, and the nurse should assess tube
placement in this way prior to taking any other action (C). (A and B) are not indicated. The auscultating
method (D) has been found to be unreliable for small-bore feeding tubes.
Correct Answer: C
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse
that he understands he is to take three doses of the medication each day. Since, at the time of
discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the
client to follow?
A. 9 a.m., 1 p.m., and 5 p.m.
B. 8 a.m., 4 p.m., and midnight.
C. Before breakfast, before lunch and before dinne
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