Online NCLEX Practice Test about
Management of Care I

1. A client is hospitalized and has a cardiac catheterization. Upon return to the unit, the nurse assigns this client to the unlicensed assistive personnel (UAP) for morning care. What should the nurse tell the UAP about this client?

a. “This client will be on bed rest for 24 hours.”
b. “Increase this client’s IVF rate in order to clear the catheterization dye.”
c. “Keep the head of the bed elevated to 90 degrees.”
d. “Assist this client with meals so the head is not raised.”

2. An 81-year-old one day post cholecystectomy is NPO and has an IVF rate of 125 cc/hr. the nurse hears in report that the client has become increasingly agitated. On initial rounds, the nurse finds the client disoriented to place and time with a blood pressure of 180/100 mm Hg and a respiratory rate of 40/ minute. The nurse’s next action should be to:

a. Instruct the client to remain in bed
b. Call the physician
c. Auscultate the client’s lung sounds
d. Restrain the client

3. Two nurses are having lunch in the cafeteria. They begin discussing a client who was physically abused by a boyfriend. Their discussion was overheard by the client’s family member, who became extremely distraught. What are the consequences of this incident?

a. The nurses can be liable for slander
b. The nurses may have their licenses revoked by the state board
c. None, because the family member should not have eavesdropped on the nurses’ conversation
d. The family member and nurses can now discuss this further to provide safety of the client

4. When a nurse colleague is suspected of working while under the influence of alcohol, which action should be initially implemented?

a. Confront the individual personally
b. Record specific dates and behaviors observed
c. Casually mention the issue with the immediate supervisor
d. Request a transfer to another unit to avoid legal consequences

5. A nurse is in charge of 15 acute care clients on a busy evening shift. The staff consists of the nurse, an unlicensed assistive technician (UAP), and an LPN. Which of the following activities can the nurse delegate to the LPN?

a. The admission of a client admitted through the clinic for hypertension
b. Stat IM injection for pain relief
c. Ambulating a post-op client
d. Transcription of a physician’s orders

6. A client with Guillain-Barre syndrome has been on ventilator and can only communicate with eye blinks because of quadriplegia. The intensive care nursing staffs sometimes have no time for this tedious communication process. The client’s family comes infrequently since they run a family-owned restaurant that does not close until visiting hours are over. How should the nurse respond to the family’s request for exemption from visiting hours?

a. Arrange for a volunteer to stay with the client during the day to provide for socialization needs and to facilitate communication with staff
b. Explain to the family that consistency in enforcing rules is important to prevent complaints from the families of other clients.
c. Suggest that the family visit in shifts during the normal visiting hours, since the client need to sleep at night
d. Make an exception to visiting regulations because of the long-term nature of the client’s recovery and the need for family support

7. A therapeutic nurse-client relationship begins with the nurse’s:

a. Sincere desire to help others
b. Acceptance of others
c. Self-awareness and understanding
d. Sound knowledge of psychiatric nursing

8. A client who has been rape is brought to emergency room of an acute care hospital. The nurse in charge calls for a sexual assault nurse examiner. While waiting for the nurse to arrive, the priority of the staff nurse would be to:

a. Offer psychological counseling
b. Check for any bruises
c. Preserve the evidence
d. Provide a shower and change of clothes for the client

9. A client with cancer has been advised by the physician that he should have chemotherapy. The client is concerned about chemotherapy and wants to take herbal treatments instead. The nurse’s best response to the client is which of the following?

a. “You are making a mistake and placing your life in jeopardy.”
b. “Herbal treatments are not approved by the FDA.”
c. “Herbal treatments have not been researched with cancer.”
d. “Tell me about your concerns with chemotherapy.”

10. A client has reddened area over a bony prominence. The nurse finds a nursing assistant massaging this area. The nurse should:

a. Reinforce the nursing assistant’s use of this intervention over the bony prominence
b. Explain to the nursing assistant that massage is effective because it improves blood flow to the area
c. Inform the nursing assistant that massage is even more effective when combined with the use of lotion
d. Instruct the nursing assistant that massage is contraindicated because it decreases blood flow to the area

11. The nursing staff has finished a particularly difficult restraint with an adolescent client. In addition to determining whether anyone was injured, the staffs are mandated to evaluate the incident to obtain which of the following ultimate outcomes?

a. Coordinate documentation of the incident
b. Resolve negative feelings and attitudes
c. Improve the use of restraint procedures
d. Calm down before returning to the other clients

12. When witnessing the client’s signature on consent for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. Which of the following is an unrealistic expectation for the nurse to verify?

a. That there was adequate disclosure of the information
b. That there was sufficient comprehension of information
c. That there was voluntary consent on the client’s part
d. That the client has full awareness of the rehabilitation process

13. A primigravida client at 37 weeks’ gestation who has been diagnosed with pregnancy-induced hypertension (PIH) is to be admitted to the labor and delivery area. The nurse determines that the most appropriate room for this client is:

a. A brightly lit private room at the end of the hall from the nurse’s station
b. A semi-private room midway down the hall from the nurse’s station
c. A private room with many windows that is near the operating room
d. A darkened private room as close to the nurse’s station as possible

14. The physician who elects to perform a cesarean delivery on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client’s husband says, “I’ll sign it for her. She’s too upset by what is happening to make this decision.” Which of the following would be the most correct?

a. Ask the client if this is acceptable to her
b. Have the client and her husband both sign the consent form
c. Ask the client to sign the consent form
d. Ask the doctor to witness the consent form

15. The client is a survivor of non-Hodgkin’s lymphoma. Which of the following statements indicates the client needs additional information?

a. “Regular screening is very important for me.”
b. “The survivor rate is directly proportional to incidence of second malignancy.”
c. “The survivor rate is indirectly proportionate to the incidence of second malignancy.”
d. “It is important for survivors to know the stage of the disease and their current treatment plan.”

16. What would be an appropriate outcome for an elderly client recovering from bacterial pneumonia?

a. A respiratory rate of 25 to 30 breaths/minute
b. The ability to perform activities of daily living without dyspnea
c. A maximum loss of 5 to 10 pounds of body weight
d. Chest pain that is minimized by splinting the ribcage

17. The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates which of the following?

a. Minimal leaking
b. No swelling
c. Tissue pallor
d. Evidence of bleb

18. The nurse notes that a placebo has been ordered for use when a client request pain medication. Which of the following statements is most accurate about the use of placebo in the client’ plan of care?

a. It is appropriate to substitute placebos when the client requests dose of pain medication frequently
b. Placebos should be used when it is suspected that the client is addicted to pain medication
c. The use of placebos violates the client’s right to ethical care
d. Placebos may be used whenever the nurse believes the client is not really experiencing pain

19. A home health nurse is giving instructions to a 65-year-old client with a new colostomy. The client states’ “I am so tired today; I just cannot think.” The nurse best action for the teaching session is to:

a. Reschedule the appointment at a time when the client is rested
b. Give the client a written instruction sheet instead of verbal teaching
c. Ask the client to concentrate because the instructions are important
d. Give the teaching session to the spouse instead of the client

20. The nurse is assigning care to the unlicensed nursing personnel (UNP) for a client with a nasogastric tube with intermittent suction after gastric surgery. Which of the following interventions cannot be delegated to the UNP?

a. Recording the output
b. Securing the nasal tape
c. Documenting the color of the drainage
d. Repositioning he tube

21. The charge nurse is making client care assignments for the evening shift. One of the licensed practical/vocational nurses (LP/VNs) is a new graduate in orientation. Which of the following clients would be an appropriate care assignment for this nurse?

a. A 41-year-old client with unstable angina
b. A 72-year-old client with diverticulitis
c. A 32-year-old client hospitalized for chemotherapy treatment
d. A 5-year-old client with Kawasaki’s disease

22. The nurse is about to medicate a woman for breast cancer lumpectomy. The client says, “I’ll be glad when the surgery is over. It will eliminate all the cancer from my body.” Which of the following is the best action for the nurse to take?

a. Medicate the client and tell the physician
b. Correct the client’s misconceptions
c. Call the doctor without medicating the client
d. Give the medication to the client and note her comment in the chart

23. The nurse is making the assignments for the floor. There is one LPN and three RNs. Which of the following rooms should the LPN be assigned to?

a. Ms. M who is intubated and Ms. L who is newly diagnosed diabetic
b. Mr. P, a recent transfer from ICU and Mr. T, a person with AIDS
c. Mr. H, awaiting a nursing home bed and Mr. D, one day post-hernia repair
d. Ms. R, a new admission for cholecystectomy and Ms. Y, one day post-op mastectomy

24. A nurse is in charge of 15 acute-care clients on a busy evening shift. The staff consists of the nurse, an unlicensed assistive personnel (UAP), and a licensed practical nurse (LPN). Which of the following activities can you delegate to the LPN?

a. The admission assessment of a client admitted through the clinic for hypertension
b. Stat IM injection for pain relief
c. Ambulating a post-op client
d. Transcription of physician’s orders

25. A home health care has been assigned to visit four clients. Based on the information provided, which client would have the highest priority when deciding on the schedule of visits?

a. A colon cancer client with a sigmoid colostomy of 2 months
b. A hypertensive client who has been complaining of an occipital headache for the past 2 days
c. A 3rd day postoperative mastectomy client with a Jackson-Pratt drain
d. A client with emphysema on low-flow oxygen who is complaining of fatigue

26. Which obstetrical client would the home care nurse plan to visit first?

a. The breastfeeding multipara who delivered via cesarean birth 5 days ago
b. The client with preterm labor and intact membranes contracting q 20-30 minutes
c. A class II cardiac with ankle edema and dyspnea after housework
d. A client of 35-weeks gestation reporting dark vaginal staining and urine tenderness

27. Four clients are admitted to a surgical unit. The nurse would begin to prepare which of the following clients for emergency surgery?

a. A client with a diagnosis of stones in the gall bladder
b. A client with a diagnosis of torsion of the testes
c. A client scheduled for a removal of a bunion who has a temperature of 101.4F
d. A client diagnosed with a breast mass

28. Following a motor vehicle accident, a client is brought to the emergency with a pneumothorax. Which of the following interventions would the nurse expect to perform first?

a. Assemble a chest-tube drainage system
b. Schedule the client for a CAT scan
c. Monitor arterial blood gases
d. Encourage coughing and deep breathing

29. When planning the assignment of a licensed practical nurse (LPN), which of these tasks would be appropriate?

a. Adding 40 mEq of potassium chloride to an infusion of 5% dextrose and water
b. Monitoring an infusion of hyperalimentation that is infusing at 100 ml per hour
c. Flushing a Port-A-Cath that is located in the subclavian area with normal saline
d. Attaching an infusion of packed cells to the side port of an infusion of normal saline

30. A home health nurse has been assigned to visit the following clients. Based on the information provided, which client should be seen first?

a. A client who had a sigmoid colostomy 2 months ago for colon cancer
b. A client who has been complaining of occipital headaches in the morning for the past two days
c. A client with a Jackson-Pratt drain and wound dressings
d. A client with emphysema who is receiving 2 liters of oxygen and who was discharged from the hospital 24 hours ago

31. When developing a discharge plan to manage the care of a client with COPD, the nurse should expect which of the following?

a. The client will develop infections easily
b. The client will maintain current status
c. The client will require less supplemental oxygen
d. The client will show permanent improvement

32. When giving a changing of shift report, which of the following statements by the nurse is not considered appropriate?

a. “Janet Mason is a 38-year-old female client of Dr. Smith with cholecystitis and cholelithiasis.”
b. “Mrs. Green’s pain is best relieved in the left lateral Sim’s position.”
c. “Mr. Brown is just contrary today and nothing is going to please him.”
d. “Mr. Martin was able to walk around the unit twice today with no complaint of dizziness.”

33. When witnessing the client’s signature on consent for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. Which of the following are a realistic expectation and requirements for an informed consent of a client?

a. That there was adequate disclosure of the information.
b. That there was no information about the risks involved and alternative means of treatment available.
c. That there was sufficient comprehension of information
d. That the client is under the influence of pre-anesthesia drugs.
e. That there was voluntary consent on the client’s part.
f. That the client has full awareness of the rehabilitation process

34. A primigravida client at 37 weeks’ gestation who has been diagnosed with pregnancy-induced hypertension (PIH) is to be admitted to the labor and delivery area. The characteristics of the room the client should be in are:

a. A brightly lit room.
b. A darkened room.
c. A semi-private room.
d. A room at the end of the hall from the nurse’s station.
e. A room with many windows that is near the operating room
f. A private room as close to the nurse’s station as possible

35. A client has been admitted to the emergency department with a diagnosis of status epilepticus. Which of the following actions by the nurse has priority?

a. Protect the client by padding the side rails
b. Administer oxygen by nonrebreather mask
c. Monitor the EKG to determine epileptogenic activity
d. Establish and maintain a patent airway

36. You are a nurse on a crowded elevator with visitors and hospital staff. Two staff members begin to discuss a client. What would be the most appropriate action by the nurse?

a. Wait till you get off the elevator and tell the staff members that they should not openly discuss clients
b. Report the situation to the supervisor
c. Confront the staff immediately and divert their conversation
d. Ignore the conversation, as this is probably the only time they would breach confidentiality

37. The parents of a sick child constantly blame each other for their child’s illness. The response by the parents that would indicate that the nurse’s attempts to point out reality had been successful would be:

a. The father bringing the child many expensive gifts
b. The parents promising the child a trip to Disney World
c. The parents making an appointment with a family counselor
d. The mother assuming the blame for not paying attention to the child’s complaints

38. An infant is scheduled for emergency surgery. The nurse notes that the baby’s mother is 13-years-old and the father is 16-years-old. The baby’s father and paternal grandmother, who cares for the baby, are at the bedside. The nurse should obtain the informed consent from the:

a. Paternal grandmother
b. Hospital administrator
c. Sixteen-year-old father
d. Thirteen-year-old mother

39. Caring for an infant who is HIV positive can best be accomplished in:

a. The pediatric unit
b. A critical unit
c. The home environment
d. An extended care facility

40. A Jewish client requests an orthodox diet while she is hospitalized. The nurse should refer this request to the:

a. Dietary department and dietitian
b. Physician
c. Nursing supervisor
d. Rabbi in pastoral care

41. A client who has been recently diagnosed with AIDS inquires about hospice services. The nurse explains that hospice care is appropriate:

a. For clients with inevitable death within weeks
b. For all clients with AIDS at any stage
c. Only for clients with cancer
d. When the client is ready to discuss his or her prognosis

42. A Mexican mother brings her 2-month old son to the emergency department with a high fever and possible sepsis. A lumbar puncture is ordered, but the mother will not sign the consent until the father arrives to give permission. The nurse is aware that:

a. This needs to be reported to the social worker
b. This needs to be reported to the children’s Protective Services
c. The Mexican man is considered the family head and makes major decisions
d. This behavior is unusual for Mexican cultural norms

43. Which of the following is appropriate to include in an incident report?

a. An interpretation of the likely cause of the incident
b. What the nurse saw and did
c. The client’s statement about the incident that occurred
d. The extenuating circumstances involved in the situation

44. A prominent member of society is hospitalized with a diagnosis of pneumonia. People are calling to ask about his condition. The nurse should:

a. Refer them to his physician
b. Refer them to a family member
c. Give them a report on his condition
d. Refer them directly to the patient


45.
The nurse is reviewing signed consent forms included in the patient care records. A parent must give permission for which of the following procedures?

a. A 15-year-old who is sexually active and request contraceptives services
b. A 16-year-old who is married and is schedule for a hernia repair
c. A 17-year-old who is away at boarding school and is scheduled for an open reduction of a fractured tibia
d. A 14-year-old who is 4 months pregnant and is scheduled for an amniocentesis

46. After several months of hemodialysis, a client with chronic renal failure refuses to continue with treatment. It is most important for the nurse to:

a. Ask the client’s family to encourage the client to change her mind
b. Ask another client undergoing dialysis to talk to the client
c. Ensure that the client’s statements are recorded without judgment in the chart
d. Ensure that the client has been told the eventual results of the refusal of care

47. A nursing assistant becomes ill at work and prepares to go home. The supervising nurse should ask the nursing assistant to:

a. Explain what task have been completed, and which tasks remain to be done
b. Distribute any uncompleted tasks to the other nursing assistants
c. Leave a written list of the tasks that still need to be completed
d. Report the nursing care that needs to be accomplished

48. Which of the following action, if performed by a nurse, would be considered negligence?

a. The nurse does not aspirate prior to injecting heparin SC into a patient’s abdomen
b. The nurse removes wrist restraints hourly and puts the patient’s arms through passive range of motion exercise
c. The nurse checks the pedal pulses two hours after a patient returns from a cardiac catheterization
d. The nurse administers a preoperative injection to a patient prior to removing the patient’s dentures

49. Which of the following approaches should the nurse use with the family when a posttraumatic stress disorder (PTSD) client states, “My family doesn’t believe anything about posttraumatic stress disorder?”

a. Provide the family with information
b. Teach the family about problem solving
c. Discuss the family’s view of the problem
d. Assess for the presence of family violence

50. A nursing assistant tells a nurse, “The client with amnesia looks fine but responds to questions in vague, distant manner. What should I be doing for her?” which of the following responses is the most appropriate?

a. “Gives her lots of space to test her independence.”
b. “Keep her busy and make sure she doesn’t take a nap during the day.”
c. “Whenever you think she needs direction, use short simple sentences.”
d. “Spend as much time with her as you can, ask questions about her recent life.”

51. The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates which of the following?

a. Minimal leaking
b. No swelling
c. Tissue pallor
d. Evidence of bleb

52. The nurse notes that a placebo has been ordered for use when a client request pain medication. Which of the following statements is most accurate about the use of placebo in the client’ plan of care?

a. It is appropriate to substitute placebos when the client requests dose of pain medication frequently
b. Placebos should be used when it is suspected that the client is addicted to pain medication
c. The use of placebos violates the client’s right to ethical care
d. Placebos may be used whenever the nurse believes the client is not really experiencing pain

53. A home health nurse is giving instructions to a 65-year-old client with a new colostomy. The client states, “I am so tired today; I just cannot think.” The nurse best action for the teaching session is to:

a. Reschedule the appointment at a time when the client is rested
b. Give the client a written instruction sheet instead of verbal teaching
c. Ask the client to concentrate because the instructions are important
d. Give the teaching session to the spouse instead of the client

54. The nurse is assigning care to the unlicensed nursing personnel (UNP) for a client with a nasogastric tube with intermittent suction after gastric surgery. Which of the following interventions cannot be delegated to the UNP?

a. Recording the output
b. Securing the nasal tape
c. Documenting the color of the drainage
d. Repositioning the tube

55. The charge nurse is making client care assignments for the evening shift. One of the licensed practical/vocational nurses (LP/VNs) is a new graduate in orientation. Which of the following clients would be an appropriate care assignment for this nurse?

a. A 41-year-old client with unstable angina
b. A 72-year-old client with diverticulitis
c. A 32-year-old client hospitalized for chemotherapy treatment
d. A 5-year-old client with Kawasaki’s disease

56. The nurse is about to medicate a woman for breast cancer lumpectomy. The client says, “I’ll be glad when the surgery is over. It will eliminate all the cancer from my body.” Which of the following is the best action for the nurse to take?

a. Medicate the client and tell the physician
b. Correct the client’s misconceptions
c. Call the doctor without medicating the client
d. Give the medication to the client and note her comment in the chart

57. The nurse is making the assignments for the floor. There is one LPN and three RNs. Which of the following rooms should the LPN be assigned to?

a. Ms. M who is intubated and Ms. L who is newly diagnosed diabetic
b. Mr. P, a recent transfer from ICU and Mr. T, a person with AIDS
c. Mr. H, awaiting a nursing home bed and Mr. D, one day post-hernia repair
d. Ms. R, a new admission for cholecystectomy and Ms. Y, one day post-op mastectomy

58. A nurse is in charge of 15 acute-care clients on a busy evening shift. The staff consists of the nurse, an unlicensed assistive personnel (UAP), and a licensed practical nurse (LPN). Which of the following activities can you delegate to the LPN?

a. The admission assessment of a client admitted through the clinic for hypertension
b. Stat IM injection for pain relief
c. Ambulating a post-op client
d. Transcription of physician’s orders

59. A home health care has been assigned to visit four clients. Based on the information provided, which client would have the highest priority when deciding on the schedule of visits?

a. A colon cancer client with a sigmoid colostomy of 2 months
b. A hypertensive client who has been complaining of an occipital headache for the past 2 days
c. A 3rd day postoperative mastectomy client with a Jackson-Pratt drain
d. A client with emphysema on low-flow oxygen who is complaining of fatigue

60. Which obstetrical client would the home care nurse plan to visit first?

a. The breastfeeding multipara who delivered via cesarean birth 5 days ago
b. The client with preterm labor and intact membranes contracting q 20-30 minutes
c. A class II cardiac with ankle edema and dyspnea after housework
d. A client of 35-weeks gestation reporting dark vaginal staining and urine tenderness

61. Four clients are admitted to a surgical unit. The nurse would begin to prepare which of the following clients for emergency surgery?

a. A client with a diagnosis of stones in the gall bladder
b. A client with a diagnosis of torsion of the testes
c. A client scheduled for a removal of a bunion who has a temperature of 101.4F
d. A client diagnosed with a breast mass

62. Following a motor vehicle accident, a client is brought to the emergency with a pneumothorax. Which of the following interventions would the nurse expect to perform first?

a. Assemble a chest-tube drainage system
b. Schedule the client for a CAT scan
c. Monitor arterial blood gases
d. Encourage coughing and deep breathing

63. When planning the assignment of a licensed practical nurse (LPN), which of these tasks would be appropriate?

a. Adding 40 mEq of potassium chloride to an infusion of 5% dextrose and water
b. Monitoring an infusion of hyperalimentation that is infusing at 100 ml per hour
c. Flushing a Port-A-Cath that is located in the subclavian area with normal saline
d. Attaching an infusion of packed cells to the side port of an infusion of normal saline

64. A home health nurse has been assigned to visit the following clients. Based on the information provided, which client should be seen first?

a. A client who had a sigmoid colostomy 2 months ago for colon cancer
b. A client who has been complaining of occipital headaches in the morning for the past two days
c. A client with a Jackson-Pratt drain and wound dressings
d. A client with emphysema who is receiving 2 liters of oxygen and who was discharged from the hospital 24 hours ago

65. When developing a discharge plan to manage the care of a client with COPD, the nurse should expect which of the following?

a. The client will develop infections easily
b. The client will maintain current status
c. The client will require less supplemental oxygen
d. The client will show permanent improvement

66. When giving a changing of shift report, which of the following statements by the nurse is not considered appropriate?

a. “Janet Mason is a 38-year-old female client of Dr. Smith with cholecystitis and cholelithiasis.”
b. “Mrs. Green’s pain is best relieved in the left lateral Sim’s position.”
c. “Mr. Brown is just contrary today and nothing is going to please him.”
d. “Mr. Martin was able to walk around the unit twice today with no complaint of dizziness.”

67. Which of the following assessment findings would the nurse expect unlicensed assistive personnel (UAP) to identify in a client who has urinary retention?

a. Faint bowel sounds
b. Bulge
c. Swollen ankles
d. Restlessness or confusion

68. Which of the following best assists the nurse in evaluating the effectiveness of a client’s medication regimen?

a. Asking the client’s family
b. Therapeutic serum levels
c. The clinical response of the client
d. Discussing the progress with the multidisciplinary treatment team

69. Comprehensive individualized care that is provided by the same nurse throughout the period of hospitalization is known as:

a. Case management
b. Team nursing
c. Community nursing
d. Primary nursing

70. Which of the following is true about discharge planning?

a. It is now completed only by case managers
b. Social workers must always be involved
c. It always begins upon admission
d. The physician will guide the process

71. A client misses one period after being on the pill for 3 months. The nurse should assess her first for:

a. Illness
b. Anorexia
c. Pregnancy
d. Compliancy

72. Before discharge the nurse should teach the non-breastfeeding mother that if breast engorgement occurs, she should:

a. Wear a tightly fitted brassiere
b. Take 2 aspirins every 4 hours
c. Cease drinking milk for 2 weeks
d. Apply hot compresses to the breasts

73. A client has been in the manic phase of bipolar disorder for the past 8 days. During this time, he has been hyperactive, hasn’t sat down to eat meals, and has slept only 2 hours each night. Which strategy should the nurse use to help the client get adequate rest?

a. Establish a bedtime routine
b. Place the client in seclusion during the night
c. Prevent the client from sleeping during the day
d. Encourage the client to catnap throughout the day

74. A 2-year-old child is in Bryant’s traction. Which measure should the nurse take to feed this child?

a. Adjust the traction so the child can be turned to one side to eat
b. Temporarily stop the traction so the child can sit uptight to eat
c. Ask the child’s mother about the child’s favorite eating position
d. Maintain the child in proper traction alignment during meals

75. The nurse on a psychiatric unit is assigned to stay with a severely depressed client. The nurse needs to go to the lavatory. How should the nurse manage this situation?

a. Have another staff member inform the nurse manager of the need for a replacement
b. Tell the client that the nurse will return in a few minutes
c. Ask another client to sit in for a while
d. Discontinue observation only when the client states that the depression has lifted

76. A client in an alcohol treatment center admits to drinking two to three cases of beer every weekend and reports experiencing several blackouts in the past few months. Which recommendation by the nurse would be most appropriate?

a. Monitor alcohol intake for the nest 3 months
b. Reduce alcohol intake and attend Alcoholic Anonymous meetings
c. Limit drinking to special occasions only
d. Abstain from alcohol altogether

77. The nurse assigns an unlicensed assistive personnel to provide care for a client who is at risk for hemorrhaging. After carefully reviewing the clinical care with the aide, which of the following questions should the nurse ask to assure client safety?

a. “Do you understand my instruction?”
b. “Do you have any questions?”
c. “Can you repeat the main points I have told you?”
d. “Will you be able to complete the assignment in the allotted time?”

78. The nursing diagnosis that is most appropriate for children with lead poisoning is:

a. Risk for injury
b. Chronic pain
c. Altered nutrition
d. Unilateral neglect

79. A 3-month-old infant has a ventriculoperitoneal shunt inserted. The nurse plans to:

a. Keep the infant in the prone position
b. Apply sterile moist dressings to the incision
c. Observe for signs of leakage of CSF
d. Teach the parents the signs of increased ICP

80. A client with terminal cancer tells the nurse that she is not afraid to die and she is thinking about how to plan her funeral. The most appropriate referral the nurse could suggest would be to:

a. Home health care worker
b. Social worker
c. Psychologist
d. Pastoral care department

81. The guidelines for evaluating registered nurse professional conduct are contained in the:

a. Standards of Care
b. Patient’s Bill of rights
c. Code of Ethics
d. Professional certification

82. Which of the following clients would be most appropriate for the nurse to assign to the unlicensed assistant for morning care?

a. An elderly client with COPD who is receiving oxygen therapy for mild dyspnea
b. A middle-aged client who had a laryngectomy 2 days earlier
c. A young client receiving chemotherapy for Hodgkin’s disease
d. An elderly experiencing chest pain due to suspected pulmonary embolus

83. A nurse fails to give the evening does of an IV antibiotic that is to be administered every 12 hours. The nurse’s first action is to:

a. Report the incident to the physician
b. Assess the client for increasing signs of infection
c. Administer the dosage 6 hours late
d. Call the pharmacist for instruction

84. A nurse is assigned to four clients on the in-patient psychiatric unit. Which client should the nurse evaluate first?

a. A client who is refusing to attend group therapy
b. A client who is complaining of dry mouth and sore throat
c. A client who needs a stat injection of fluphenazine decanoate (Prolixin)
d. A client who has a BP of 90/64 mmHg and is to receive a morning dose of sertraline (Zoloft)

85. A 4-year-old girl is scheduled for a bone marrow aspiration. Which nursing action would help prepare her for this procedure?

a. Using a doll to show her what will happen during the procedure
b. Telling her a story about a little girl who had the procedure
c. Discussing the procedure with the parents and letting them explain it to her
d. Asking her parents if she knows anyone who has had this procedure

86. A nurse enters the room of a client who had a left modified mastectomy 8 hours earlier. Which of the following observations indicates that the nursing assistant assigned to the client needs further instruction and guidance?

a. The client is squeezing a ball in her left hand
b. The client is wearing a robe with elastic cuffs
c. The client’s affected arm is elevated on a pillow
d. A blood pressure cuff is on the client’s right arm

87. A 50-year-old client is scheduled for electroconvulsive therapy (ECT). The nurse knows that ECT is most commonly prescribed for which of the following conditions?

a. Major depression
b. Antisocial personality disorder
c. Chronic schizophrenia
d. Somatoform disorder

88. Which of the following interventions would help a client diagnosed with Alzheimer’s disease perform activities of daily living?

a. Have the client perform all basic care without help
b. Tell the client morning care must be done by 9 a.m.
c. Give the client a written list of activities he’s expected to do
d. Encourage the client, and give ample time to complete basic tasks

89. Stomatitis is a common side effect of chemotherapy. To limit this side effect, the teaching plan for a client who is receiving chemotherapy should include instructions to:

a. Rinse the mouth 3 times a day with lemon juice and water
b. Brush the teeth once daily and use dental floss after each meal
c. Vigorously cleanse the mouth with toothpaste and a firm toothbrush
d. Frequently cleanse the mouth with a soft toothbrush or a power spray

90. Prior to a total laryngectomy, an important aspect of preoperative nursing care includes:

a. Having speech therapist visit the client
b. Adequate explanation of the nature of surgery to be preformed
c. Basing instruction on those areas in which the client has questions
d. Instruction in breathing exercises and/or equipment used postoperatively to prevent complications

91. When reviewing the laboratory results for a client in acute renal failure, the nurse notes that the serum potassium level is 6.2 mEq. The nurse should first:

a. Call the cardiac arrest team to alert them
b. Call the laboratory to schedule a repeat test
c. Obtain an ECG strip and have lidocaine available
d. Take the client’s vital signs and notify the physician

92. During the preoperative teaching before a transurethral prostatectomy, the nurse tells the client that after the surgery:

a. His urine will be bright red for at least 24 to 48 hours
b. He can expect spasms of the bladder during the first 24 to 48 hours
c. Oral fluids should be avoided because of continuous urinary irrigation
d. He should use the Valsalva maneuver to decrease bladder contractions

93. An adult male is scheduled for exploratory surgery this morning. After he is premedicated for surgery the nurse reviews his chart and discovers that he has not signed a consent form. The nurse’s action is based on which of the following understanding?

a. Since the client came to the hospital, consent is implied even if the consent for the surgery has not been signed
b. All invasive procedures require a consent form
c. The nurse should have him sign a consent form immediately
d. The nurse should have the next of kin sign the necessary consent form

94. A 25-year-old woman had surgery today. Her father, a physician but not her surgeon, enters the nursing action and asks for her chart. The best action for the nurse to take is:

a. To give him the chart as requested
b. Not to allow him to read the chart
c. To ask the attending surgeon if it is permissible for him to read the chart
d. To ask the client if she wants him to read her chart

95. A client is admitted to the floor. She is in the terminal stage of AIDS. During the admission assessment, the nurse would ask her if she had which of the following?

a. A will
b. A do not resuscitate (DNR) order
c. An organ donation card
d. Healthcare proxy

96. The nurse enters a client’s room to administer 10 mg Valium PO, the ordered pre-op medication for her hysterectomy. During the conversation, the client tells the nurse that she and her husband are planning to have another child in the coming year. The best action for the nurse to take is which of the following?

a. Do not administer the pre-op medication; notify the nursing supervisor and the physician
b. Go ahead and administer the medication as ordered
c. Check to see if the patient has signed a surgical consent
d. Send the patient to the operating room without the medication

97. The nurse notes that a previous shift administered the wrong does of a medication. The nurse’s best response is which of the following?

a. Assess the client and fill out an incident form
b. Notify the immediate supervisor and the physician
c. Discuss the potential outcomes with a colleague
d. Call the client’s family and explain the situation

98. Written instruction for the client at the time of discharge should include which of the following information?

a. A copy of the completed discharge summary
b. A completed form from the physician
c. Medical treatment, and follow-up information
d. Complete name and addresses of any consultants

99. When documenting a client’s response to pain medication, which of the following statements would the nurse record?

1. Client appears comfortable and is resting without complaints at this time
2. Client appears to tolerate pain poorly, even after medication was given
3. Pain medication given with relief of pain 30 minutes after injection
4. Client reports pain to be a 3 on a 1 to 10 scale, with 10 being most severe pain

100. A registered nurse is preparing an assignment for a medical surgical unit. An unlicensed assistive person (UAP) should never be assigned to:

1. Assist physician with surgical procedure
2. Bathe a patient in traction
3. Ambulate a postoperative client
4. Bathe a cardiac client




ANSWERS AND RATIONALE

1) D
- following catheterization, clients need assistance with meals because the head of the bed is usually not permitted to be greater than 30 degrees. The UAP should not regulate IV drips.

2) C
- given the client’s age, respiratory rate, and IVF rate, the nurse should first complete a respiratory assessment. A confused client is not likely to follow instructions. Restraints should not be applied immediately unless the client is clearly a danger to herself and to others.

3) A
- charges of defamation of character, either written (libel) or oral (slander) can be brought if confidential information regarding clients is divulged that harms his reputation. Nurses are supposed to uphold the Standards of Practice.

4) B
- organizing and documenting the alleged behaviors is the first step if there is a problem; then discuss the matter with the immediate supervisor.

5) B
- it is within the scope of practice for an LPN to administer IM injections. In certain states, it is also within the LPN scope of practice to insert intravenous lines when the LPN has undergone specialized training. Only nurses can perform assessments and are permitted to transcribe physician orders in acute care facilities. An RN, LPN or UAP could perform ambulation of the patient.

6) D
- Guillain-Barre syndrome is characterized by the onset of ascending paralysis which may include respiratory muscles. Person with Guillain-Barre syndrome may remain ventilator-dependent for weeks, but have full consciousness. The prognosis for recovery from Guillain-Barre syndrome good, but is very much dependent upon the level of supportive care during the acute stage.

7) C
- although all of the options are desirable, knowledge of self is the basis for building a strong, therapeutic nurse-client relationship. Being aware of and understanding personal feelings and behavior is a prerequisite for understanding for understanding and helping clients.

8) C
- the priority for the staff nurse would be not to destroy any of the evidence, which could be used if the case goes to court. The sexual assault nurse examiner would do a thorough examination and would document and photograph injuries sustained during the incident. Having the client bathe, comb her hair or remove clothing could destroy evidence.

9) D
- asking the client to speak about his concerns encourages open discussion. Telling the client that he is making a mistake is judgmental of the client’s wishes and eliminates opportunities for the client to explore the situation and discuss various treatment options. Saying that herbal treatments have not been approved by the FDA or that they have not been researched is irrelevant, places a value judgment on the client’s wishes, and provides no opportunity for discussion.

10) D
- massaging the area that is reddened due to pressure is contraindicated because it further reduces blood flow to the area. In the past, massaging reddened areas was thought to improve blood flow to the area, and some nursing personnel may still believe that massaging the area is effective in preventing ulcer formation.

11) C
- although coordinating documentation, resolving negative feelings and calming down are goals of debriefing after a restraint, the ultimate outcome is to improve restraint procedures.

12) D
- the role of the nurse in witnessing the signing of the consent is not to witness that the client is fully aware of the rehabilitation. The nurse’s role is to witness that the client is informed of the procedure, understands the information and is signing of his or her own free will

13) D
- A primigravid diagnosed with PIH has the potential for developing seizures. This client should be in a room with the least amount of stimulation possible to reduce the risks for seizures and as close to the nurse’s station as possible in case the client requires immediate assistance. Bright lighting and sunshine can be a stimulant, possibly increasing the risks for seizures, as can being in semi-private room with roommate, visitors, conversation and noise.

14) C
- Preparation for cesarean delivery is similar to preparation for any surgery. The client must give informed consent. Another person may not sign for the client unless the client is unable to sign the form. If this is the case, only certain designated people can do so legally. The husband does not need to sign the form unless the wife is unable to do so. In an emergency situation, surgery may me performed without a written consent if it is done to save the life of the mother or the child, or both.

15) B
- It is incorrect that the survivor rate is directly proportional to the incidence of second malignancy. The survivor rate is indirectly proportional to the incidence of second malignancy, and regular screening is very important to detect a second malignancy, especially AML or myelodyplasic (MDS). Survivors should know the stage of the disease and their current treatment plan so that they can remain active participants in their health care.

16) B
- An expected outcome for a client recovering from pneumonia would be the ability to perform activities of daily living without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/minute indicates that the client is experiencing tachypnea, which would not be expected on recovery. A weight loss of 5 to 10 pounds is undesirable; the expected outcome would be to maintain normal weight. A client who is recovering from pneumonia should experience decreased or no chest pain.

17) D
- a properly administered intradermal injection shows evidence of bleb at the injection site. There should be no leaking of medication from the bleb; it needs to be absorbed into the tissue. Lack of swelling at the injection site means that the injection was given too deeply. The presence of tissue pallor does not indicate that the injection was given correctly.

18) C
- the client has a right to accurate care information and participation in decision making about treatment options. The use of placebos is misleading to the client and unethical because it does not represent full disclosure about the treatment the client is receiving. The nurse cannot determine whether a client is in pain; pain is what the client says it is.

19) A
- the client’s readiness to learn is compromised by fatigue and lack of concentration. The teaching session should be rescheduled to a better time for improved learning readiness. Written instructions or involving the spouse can supplement verbal instructions but cannot replace teaching the client directly.

20) D
- repositioning the tube in a client who has undergone gastric surgery should be preformed (per order of the surgeon) by the registered nurse. Recording output, securing nasal tape and documenting the color of the drainage could safely be delegated to the UNP.

21) B
- a client with diverticulitis will need care that the LP/VN should be able to provide safely. The client with angina is unstable and requires a registered for continuous assessment. The client receiving chemotherapy treatment requires a registered nurse who is certified in chemotherapy administration. A child with Kawasaki’s disease must be watched closely for cardiac complications, and it would be best to assign the child to an experienced pediatric nurse, not a new graduate.

22) C
- medicating the client can cloud her judgment and should be withheld. The doctor is the person to clarify the misconceptions

23) C
- these clients are the least sick and require the least amount of highly skilled nursing care. Other client must be assigned to the RNs for a high-level, skilled nursing care.

24) B
- it is within the scope of practice for an LPN to administer IM injections. In certain states, it is also within the LPN scope of practice to insert IV lines when the LPN has undergone specialized training.

25) B
- occipital headaches in a client who is hypertensive is a classical sign of elevated BP and should be assessed first.

26) D
- the client may be experiencing premature separation of the placenta; a condition hat may lead to serious fetal and maternal complications. Although, the nurse may be concerned about wound healing and infant feeding, breastfeeding reduces the risk of the most serious complication, postpartum hemorrhage. The nurse would be most concerned with rupture of the membranes and contractions in excess4 to 6 per hour. Ankle edema is common in pregnancy and dyspnea following activity is anticipated in the class II cardiac patient.

27) B
- torsion of the testes requires immediate surgery because when the testes are twisted, irreversible damage occurs in approximately 6 hours.

28) A
- the primary intervention for pneumothorax is chest tube insertion. A drainage system is required to restore intrapleural pressure. The client would not be scheduled for a CAT scan. The ABG would be monitored but this is not the priority. Coughing and deep breathing is not the priority.

29) B
- monitoring a hyperalimentation infusion is within legal boundaries of the LPN role. Without additional preparation, nurse practice laws in most states do not allow the LPN to add medication to IV infusions.

30) B
- a complaint of occipital headache in a client who has hypertension may indicate that the client is hypertensive. Other symptoms include dizziness, fatigue, palpitations, blurred vision, and epistaxis. If the client’s BP is elevated, he is at risk for complications and thus should be seen first.

31) A
- A client with COPD is at high risk for development of respiratory infections. COPD is slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely.

32) C
- this statement is critical in nature and judgmental on the nurse’s part. It is inappropriate for the nurse to make a comment like this at shift report or at any time.

33) A, C, and E
- the role of the nurse in witnessing the signing of the consent is not to witness that the client is fully aware of the rehabilitation. The nurse’s role is to witness that the client is informed of the procedure, understands the information and is signing of his or her own free will

34) B and F
- A primigravid diagnosed with PIH has the potential for developing seizures. This client should be in a room with the least amount of stimulation possible to reduce the risks for seizures and as close to the nurse’s station as possible in case the client requires immediate assistance. Bright lighting and sunshine can be a stimulant, possibly increasing the risks for seizures, as can being in semi-private room with roommate, visitors, conversation and noise.

35) D
- vigorous muscular and metabolic activity may interfere with respirations. Secretions commonly accumulate and block airways during seizure activity. Metabolic activity causes increased uptake of oxygen, and secretions impair the patency of the client’s airway. The client experiencing status epilepticus is at profound risk of central nervous system ischemia and brain death unless airway patency is established and maintained.

36) C
- the staff members should not continue the conversation. Visitors would be aware that confidentiality is respected within the institution. It is the nurse’s ethical responsibility.

37) C
- the parents need assistance in exploring their feelings and their family relationships with a professional.

38) C
- regardless of age, parenthood confers the rights of an adult on the teenager. The mother has a legal right to give consent but is not available.

39) C
- unless the child has an episode of acute illness, the home is the best place for the child; this prevents nosocomial infection and promotes family interactions

40) A
- the dietary department should meet with the client to ensure that the foods are available and prepared according to religious beliefs. On admission, all clients should be asked whether they have special dietary needs. The dietary department should be notified of these special needs and a dietary representative should meet with the client and/or family when possible.

41) A
- hospice programs are appropriate programs for clients with any type of terminal illness when death is imminent within weeks up to 6 months. Clients may discuss their prognosis of a terminal illness long before it progresses to the terminal stage when a referral to hospice care is indicated.

42) C
- in the traditional Mexican household, the man is the head of the family and makes the major decisions. Efforts should be made to reach the father as soon as possible to acquire his permission. Contacting the social worker does not reflect the nurse’s need to understand a client’s cultural values and how they affect medical care decisions. This is not a situation of suspected child abuse.

43) B
- the incident reports includes only what the nurse saw and did, the objective data. The nurse does not try to interpret the likely cause of the incident, include statements from the client about the incident, or comment on extenuating circumstances.

44) B
- the family is in the best position to bridge or mediate between patient and society, this maintains confidentiality. There is no need to involve the physician at this point. Referring them to the patient may be too tiring for the patient especially since a major problem with pneumonia is fatigue.

45) C
- this person is a minor and the surgery is not an emergency surgery. Minors that can provide own consent for treatment include married minors, emancipated and mature minors, minors seeking birth control services.

46) B
- the right of competent adult to refuse treatment is guaranteed by Constitution; information would be provided by physician. The client has a right to refuse treatment. Documentation is not the most important, client’s understanding of her decision is most important.

47) A
- this provides continuity of care and meets patient’s needs. Tasks should be communicated verbally so questions can be asked and answered, task completed should be discussed.

48) C
- checking the pedal pulses after a cardiac catheterization should be done immediately after the procedure and repeated every 15 minutes or several hours to detect changes in circulation.

49) A
- if the family can understand PTSD, they can more readily participate in the client’s care and be supportive. Learning problem solving skills doesn’t help clarify PTSD. After giving the family information about PTSD, the family can then ask questions and present its views. The family must first have information about PTSD; then, the discussion about violence to self or others can be addressed.

50) C
- disruptions in the ability to perform basic care, confusion, and anxiety are often apparent in clients with amnesia. Offering simple directions to promote daily functions and reduce confusion helps increase feelings of safety and security. Giving her space may make her feel insecure. Asking her many questions that she won’t be able to answer just intensifies her anxiety level. There is no significant rationale for keeping her busy all day with no rest periods; the client may become more tired and less functional at other basic tasks.

51) D
- a properly administered intradermal injection shows evidence of bleb at the injection site. There should be no leaking of medication from the bleb; it needs to be absorbed into the tissue. Lack of swelling at the injection site means that the injection was given too deeply. The presence of tissue pallor does not indicate that the injection was given correctly.

52) C
- the client has a right to accurate care information and participation in decision making about treatment options. The use of placebos is misleading to the client and unethical because it does not represent full disclosure about the treatment the client is receiving. The nurse cannot determine whether a client is in pain; pain is what the client says it is.

53) A
- the client’s readiness to learn is compromised by fatigue and lack of concentration. The teaching session should be rescheduled to a better time for improved learning readiness. Written instructions or involving the spouse can supplement verbal instructions but cannot replace teaching the client directly.

54) D
- repositioning the tube in a client who has undergone gastric surgery should be preformed (per order of the surgeon) by the registered nurse. Recording output, securing nasal tape and documenting the color of the drainage could safely be delegated to the UNP.

55) B
- a client with diverticulitis will need care that the LP/VN should be able to provide safely. The client with angina is unstable and requires a registered for continuous assessment. The client receiving chemotherapy treatment requires a registered nurse who is certified in chemotherapy administration. A child with Kawasaki’s disease must be watched closely for cardiac complications, and it would be best to assign the child to an experienced pediatric nurse, not a new graduate.

56) C
- medicating the client can cloud her judgment and should be withheld. The doctor is the person to clarify the misconceptions

57) C
- these clients are the least sick and require the least amount of highly skilled nursing care. Other client must be assigned to the RNs for a high-level, skilled nursing care.

58) B
- it is within the scope of practice for an LPN to administer IM injections. In certain states, it is also within the LPN scope of practice to insert IV lines when the LPN has undergone specialized training.

59) B
- occipital headaches in a client who is hypertensive is a classical sign of elevated BP and should be assessed first.

60) D
- the client may be experiencing premature separation of the placenta; a condition hat may lead to serious fetal and maternal complications. Although, the nurse may be concerned about wound healing and infant feeding, breastfeeding reduces the risk of the most serious complication, postpartum hemorrhage. The nurse would be most concerned with rupture of the membranes and contractions in excess4 to 6 per hour. Ankle edema is common in pregnancy and dyspnea following activity is anticipated in the class II cardiac patient.

61) B
- torsion of the testes requires immediate surgery because when the testes are twisted, irreversible damage occurs in approximately 6 hours.

62) A
- the primary intervention for pneumothorax is chest tube insertion. A drainage system is required to restore intrapleural pressure. The client would not be scheduled for a CAT scan. The ABG would be monitored but this is not the priority. Coughing and deep breathing is not the priority.

63) B
- monitoring a hyperalimentation infusion is within legal boundaries of the LPN role. Without additional preparation, nurse practice laws in most states do not allow the LPN to add medication to IV infusions.

64) B
- a complaint of occipital headache in a client who has hypertension may indicate that the client is hypertensive. Other symptoms include dizziness, fatigue, palpitations, blurred vision, and epistaxis. If the client’s BP is elevated, he is at risk for complications and thus should be seen first.

65) A
- A client with COPD is at high risk for development of respiratory infections. COPD is slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely.

66) C
- this statement is critical in nature and judgmental on the nurse’s part. It is inappropriate for the nurse to make a comment like this at shift report or at any time.

67) B
- this is an obvious sign of urinary retention that you would expect unlicensed assistive personnel to observe. Only a nurse would be able for bowel sounds. Restlessness or confusion are late signs that UAP would have to be instructed by the nurse to observe.

68) C
- improvement of symptoms is indicative of adherence to a medication regimen, whereas noncompliance is often due to the presence of side effects.

69) D
- the stem defines primary nursing. Case management nurses do not provide direct care. Team nursing is provided by a group of nurse. Community nursing is provided in the community.

70) C
- discharge planning begins on admission in order to prepare for rapid discharge and provide for needs at home.

71) D
- noncompliance with instructions can alter hormone levels; amenorrhea can occur.

72) A
- this is like binding the breast; it reduces pain and prevents further engorgement. Cold compress would prevent further engorgement in the non-breastfeeding mother. Medications would reduce pain but would not prevent further engorgement.

73) D
- the client’s energy level is so high that a complete night’s sleep probably is impossible; the nurse should use any “down” time to promote rest. The client’s sleep pattern, including a bedtime routine, can be re-patterned when the client comes “down” from the manic phase of the disorder.

74) D
- for Bryant’s traction to be effective, it must be continuous, with the child in proper traction alignment at all times.

75) A
- a depressed client is at great risk for committing suicide and needs continuous observation. This client must not be left alone. The nurse must not relinquish responsibilities to another client.

76) D
- this client is addicted to alcohol and can’t control what happens once consumption begins. Therefore, the client must abstain altogether.

77) C
- this request a response that will give you an indication as to whether the instructions were understood.

78) A
- this is related to lead toxicity or buildup that causes fluid shifts into brain tissue, producing cell ischemia and destruction; this ultimately results in convulsions, mental retardation and death.

79) D
- the parents must be taught to identify increased intracranial pressure, since this can develop if shunt malfunction occurs.

80) D
- Spiritual support and planning for a funeral are offered by ministers, priests, and rabbis in pastoral care departments. Home health care or a social worker may be an appropriate referral for discharge planning, but not for funeral plans. The psychologist may be an appropriate referral for meeting the needs of the dying client, but not for planning funeral.

81) A
- the Standards of Care identify criteria on which nursing care plan can be evaluated. The Patient’s Bill of Rights outlines rights to protect the client’s autonomy and access to care. The Code of Ethics outlines ethical criteria to be followed by professional nurses. Professional certification signifies that the nurse has passed an examination given by a professional organization.

82) A
- the most appropriate client to assign to an unlicensed assistant is the elderly client with COPD and mild dyspnea because of the relative stability of the client’s chronic condition. The client with a new laryngectomy requires close observation to maintain a patent airway, promote comfort, and decrease anxiety. The client who is receiving chemotherapy will need to be monitored for adverse effects related to the chemotherapy. The client will a suspected pulmonary embolus is acutely ill and requires close observation.

83) A
- the error must be reported to the physician to obtain new scheduling order. An incident report should be completed and the agency policy for medication errors should be followed. The dose should not be administered 6 hours late unless ordered by the physician. Assessing for signs and symptoms is not the nurse’s first action and should be completed routinely for clients receiving antibiotics.

84) B
- these complaints may be indicative of agranulocytosis, and the client should have a medical evaluation immediately. The client should be evaluated for any complaints related to the low BP, given fluids to drink, and have BP re-checked prior to administration of the medication. However, the client with possible agranulocytosis would be the priority.

85) A
- typically, 4 –year old child is at the preoperational level of cognitive development and has trouble understanding anything beyond her own experience. Using doll provides a near-life experience, giving the child both an understanding of the procedure and a sense of control.

86) B
- elastic cuff can contribute to the development of lymphedema and should be avoided. Blood pressure measurements in the affected arm also should be avoided. Simple exercises such as squeezing a ball help promote circulation and should be started as soon as possible after surgery. Elevation of the affected arm promotes venous and lymphatic return from the extremity.

87) A
- ECT is most commonly used for the treatment of major depression in clients who haven’t responded to antidepressants or who have medical problems that contraindicate the use of antidepressants.

88) D
- clients with Alzheimer’s disease respond to the affect of those around them. A gentle calm approach is comforting and non-threatening and a tense, hurried approach may agitate the client. The client has problems performing independently.

89) D
- chemotherapy destroys rapidly dividing cells of oral mucosa; frequent gentle oral hygiene limits additional trauma. Lemon juice would be too caustic to the compromised mucosa. Flossing would disrupt and traumatize the gum surfaces; oral hygiene is needed more than once a day.

90) C
- before teaching, the nurse must determine the client’s areas of concern. Learning increase when anxiety decreases and it is hoped that knowledge will reduce anxiety.

91) D
- vital signs monitor the cardiorespiratory status; hyperkalemia can cause serious cardiac dysrhythmia that must be treated.

92) B
- spasms result from irritation of the bladder during surgery; they decrease in intensity and frequency as healing occurs. Bright red urine 24 to 48 hours would indicate hemorrhage; drainage should be dark red and then gradually turn pink.

93) B
- all invasive procedures require informed consent. The surgery is pre-scheduled and described as exploratory and therefore is not an emergency. If the client is an adult and has not been declared incompetent, the client must sign the form. This client should not have surgery performed without written consent. The nurse must notify the physician immediately.

94) B
- since he is not the client’s physician and does not have a medical need to see her chart, he should not be allowed to read the chart without written permission from the client, who is above the age of majority.

95) D
- a living will durable power of attorney for healthcare, or a healthcare proxy is an important part of admission assessment especially for terminally ill client. A will is not something the admission assessment should focus on. A living will is important for the nurse to know. Only a physician may write a DNR order.

96) A
- no patient should be administered the pre-op medication until the informed consent has been obtained. Informed consent means that the patient understands the information about the surgery. Even if the consent form is signed, the nurse should withhold sedating medication. This client clearly does not understand the planned procedure.

97) A
- client assessment is the first step to take.

98) C
- all these items should be included. It is good to have the names of consultants but it is not necessary.

99) D
- the data are reported and measured based on assessment with measurable outcomes.

100) A
- an unlicensed person is not a substitute for a registered nurse and should not assume assignments that require the skill of a registered nurse. Other options are within the scope of an unlicensed person.

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