NURS 11456 NCSBN On-line Review Exam 2019/2020 - Concord Career Colleges | NURS11456 NCSBN On-line Review Exam 2019/2020

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NURS 11456 NCSBN On-line Review Exam 2019/2020 - Concord Career Colleges NURS11456 NCSBN On-line Review Exam 2019/2020 170+ pages of well-verified questions and answers 1.A client has been hospital... ized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to A) Promote the client's comfort B) Reduce the drying time C) Decrease irritation to the skin D) Improve venous return 2.The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the client? A) Clean the meatus, begin voiding, then catch urine stream B) Void a little, clean the meatus, then collect specimen C) Clean the meatus, then urinate into container D) Void continuously and catch some of the urine 3. Following change-of-shift report on an orthopedic unit, which client should the nurse see first? A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident C) 72 year-old recovering from surgery after a hip replacement 2 hours ago D) 75 year-old who is in skin traction prior to planned hip pinning surgery. 4. A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? A) Comatose, breathing unlabored B) Glascow Coma Scale 8, respirations regular C) Appears to be sleeping, vital signs stable D) Glascow Coma Scale 13, no ventilator required 5. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug? A) Bleeding time B) Coagulation time C) Prothrombin time D) Partial thromboplastin time 6.A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first? A) Notify both the surgeon and provider B) Administer the prn dose of albuterol C) Apply oxygen at 2 liters per nasal cannula D) Repeat the peak flow reading in 30 minutes 7.A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report? A) The client lost 2 pounds in 24 hours 1B) The client’s potassium level is 4 mEq/liter. C) The client’s urine output was 1500 cc in 5 hours D) The client is to receive another dose of Lasix at 10 PM 8.A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse? A) a report of 10 pounds weight loss in the last month B) a comment by the client "I just can't sit still." C) the appearance of eyeballs that appear to "pop" out of the client's eye sockets D) a report of the sudden onset of irritability in the past 2 weeks C: the appearance of eyeballs that appear to "pop" out of the client''s eye sockets. Exophthalmos or protruding eyeballs is a distinctive characteristic of Graves'' Disease. It can result in corneal abrasions with severe eye pain or damage when the eyelid is unable to blink down over the protruding eyeball. Eye drops or ointment may be needed. 9. The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the provider immediately? A) prolonged inspiration with each breath B) expiratory wheezes that are suddenly absent in 1 lobe C) expectoration of large amounts of purulent mucous D) appearance of the use of abdominal muscles for breathing B: expiratory wheezes that are suddenly absent in 1 lobe. Acute asthma is characterized by expiratory wheezes caused by obstruction of the airways. Wheezes are a high pitched musical sounds produced by air moving through narrowed airways. Clients often associate wheezes with the feeling of tightness in the chest. However, sudden cessation of wheezing is an ominous or bad sign that indicates an emergency -- the small airways are now collapsed. 10.During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time? A) leave a book about relaxation techniques B) write out a daily exercise routine for them to assist the client to do C) list actions to improve the client's daily nutritional intake D) suggest communication strategies D: suggest communication strategies. Alzheimer''s disease, a progressive chronic illness, greatly challenges caregivers. The nurse can be of greatest assistance in helping the family to use communication strategies to enhance their ability to relate to the client. By use of select verbal and nonverbal communication strategies the family can best support the client’s strengths and cope with any aberrant behavior. 11.An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 160/100 to 180/110 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the provider? A) Slurred speech B) Incontinence C) Muscle weakness D) Rapid pulse A: Slurred speech. Changes in speech patterns and level of conscious can be indicators of continued intracranial bleeding or extension of the stroke. Further diagnostic testing may be indicated. 12. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the parent indicates that teaching has been inadequate? A) "I will keep the cast uncovered for the next day to prevent burning of the skin." B) "I can apply an ice pack over the area to relieve itching inside the cast." C) "The cast should be propped on at least 2 pillows when my child is lying down." D) "I think I remember that my child should not stand until after 72 hours." D: "I think I remember that my child should not stand until after 72 hours.". Synthetic casts will typically set up in 30 minutes and dry in a few hours. Thus, the client may stand within the initial 24 hours. With plaster casts, the set up and drying time, especially in a long leg cast which is thicker than an arm cast, can take up to 72 hours. Both types of casts give off a lot of heat when drying and it is preferable to keep the cast uncovered for the first 24 hours. Clients may complain of a chill from the wet cast and therefore can simply be covered lightly with a sheet or blanket. Applying ice is a safe method of relieving the itching. 13. Which blood serum finding in a client with diabetic ketoacidosis alerts the nurse that immediate action is required? A) pH below 7.3 B) Potassium of 5.0 C) HCT of 60 D) Pa O2 of 79% 2C: HCT of 60. This high hematocrit is indicative of severe dehydration which requires priority attention in diabetic ketoacidosis. Without sufficient hydration, all systems of the body are at risk for hypoxia from a lack of or sluggish circulation. In the absence of insulin, which facilitates the transport of glucose into the cell, the body breaks down fats and proteins to supply energy ketones, a by-product of fat metabolism. These accumulate causing metabolic acidosis (pH < 7.3), which would be the second concern for this client. The potassium and PaO2 levels are near normal. 14. The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test? A) Client should be NPO after midnight B) Client should receive a sedative medication prior to the test C) Discontinue anti-coagulant therapy prior to the test D) No special preparation is necessary D: No special preparation is necessary. This is a non-invasive procedure and does not require preparation other than client education. 15. A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this condition? A) dyspnea B) heart murmur C) macular rash D) Hemorrhage B: heart murmur. Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce findings of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli. Furthermore, the vegetations may travel to various organs such as spleen, kidney, coronary artery, brain and lungs, and obstruct blood flow. 16. The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from A) a tissue bank." B) a pig." C) my thigh." D) synthetic skin." C: my thigh.". Autografts are done with tissue transplanted from the client''s own skin. 17.A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing B) Loose, productive cough C) No relief from inhalant D) Fever and chills A: Diffuse expiratory wheezing. In asthma, the airways are narrowed, creating difficulty getting air in. A wheezing sound results. 18. A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority? A) Maintaining proper body alignment B) Frequent neurovascular assessments of the affected leg C) Inspection of pin sites for evidence of drainage or inflammation D) Applying an over-bed trapeze to assist the client with movement in bed B: Frequent neurovascular assessments of the affected leg. The most important activity for the nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage. 19. The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time? A) Daily needs and concerns B) The overview cardiac rehabilitation C) Medication and diet guideline D) Activity and rest guidelines A: Daily needs and concerns. At 2 days post-MI, the client’s education should be focused on the immediate needs and concerns for the day. 20. A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would initially assess for which problem? A) allergies B) scabies C) regression D) pinworms 3D: pinworms. Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability, restlessness, bed-wetting, distractibility and short attention span. Scabies is an itchy skin condition caused by a tiny, eight-legged burrowing mite called Sarcoptes scabiei . The presence of the mite leads to intense itching in the area of its burrows. 21. The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority? A) Risk for dehydration B) Ineffective airway clearance C) Altered nutrition D) Risk for injury B: Ineffective airway clearance. The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula at or near the bifurcation. Thus, a priority is maintaining an open airway, preventing aspiration. Other nursing diagnoses are then addressed. 22. The nurse is developing a meal plan that would provide the maximum possible amount of iron for a child with anemia. Which dinner menu would be best? A) Fish sticks, french fries, banana, cookies, milk B) Ground beef patty, lima beans, wheat roll, raisins, milk C) Chicken nuggets, macaroni, peas, cantaloupe, milk D) Peanut butter and jelly sandwich, apple slices, milk B: Ground beef patty, lima beans, wheat roll, raisins, milk. Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, and dried fruits such as raisins. This dinner is the best choice: It is high in iron and is appropriate for a toddler. 23. The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance? A) Metabolic acidosis B) Metabolic alkalosis C) Some increase in the serum hemoglobin D) A little decrease in the serum potassium B: Metabolic alkalosis. Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss of acid and lead to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse. Options C and D are correct answers but not the best answers since they are too general. 24. A two year-old child is brought to the provider's office with a chief complaint of mild diarrhea for two days. Nutritional counseling by the nurse should include which statement? A) Place the child on clear liquids and gelatin for 24 hours B) Continue with the regular diet and include oral rehydration fluids C) Give bananas, apples, rice and toast as tolerated D) Place NPO for 24 hours, then rehydrate with milk and water B: Continue with the regular diet and include oral rehydration fluids. Current recommendations for mild to moderate diarrhea are to maintain a normal diet with fluids to rehydrate. 25. The nurse is teaching parents about the appropriate diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include A) formula or breast milk B) broth and tea C) rice cereal and apple juice D) gelatin and ginger ale A: formula or breast milk. The usual diet for a young infant should be followed. 26. A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is A) call for emergency transport to the hospital B) immobilize the limb and joints above and below the injury C) assess the child and the extent of the injury D) apply cold compresses to the injured area C: assess the child and the extent of the injury. When applying the nursing process, assessment is the first step in providing care. The "5 Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis). 27. The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? A) Solid foods should be introduced at 3-4 months B) Whole milk is difficult for a young infant to digest C) Fluoridated tap water should be used to dilute milk D) Supplemental apple juice can be used between feedings B: Whole milk is difficult for a young infant to digest. Cow''s milk is not given to infants younger than 1 year because the tough, hard curd is difficult to digest. In addition, it contains little iron and creates a high renal solute load. 428. The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? A) Solid foods are introduced one at a time beginning with cereal B) Finely ground meat should be started early to provide iron C) Egg white is added early to increase protein intake D) Solid foods should be mixed with formula in a bottle A: Solid foods are introduced one at a time beginning with cereal. Solid foods should be added one at a time between 4-6 months. If the infant is able to tolerate the food, another may be added in a week. Iron fortified cereal is the recommended first food. 29. The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which one of the following as a priority? A) Limit fluids B) Client controlled analgesia C) Cold compresses to elbow D) Passive range of motion exercise B: Client controlled analgesia. Management of a sickle cell crisis is directed towards supportive and symptomatic treatment. The priority of care is pain relief. In a 12 year-old child, client controlled analgesia promotes maximum comfort. 30. The nurse is performing a physical assessment on a toddler. Which of the following actions should be the first? A) Perform traumatic procedures B) Use minimal physical contact C) Proceed from head to toe D) Explain the exam in deta - - - - - - - - - - - - - - - - - Management of Care 1. The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client A) has had a change in respiratory rate by an increase of 2 breaths B) has had a change in heart rate by an increase of 10 beats C) was minimally responsive to voice and touch D) has had a blood pressure change by a drop in 8 mmHg systolic C: was minimally responsive to voice and touch. A change in level of consciousness indicates delirium related to acute illness. This would require the assessment of a nurse. The other changes could occur within the range of normal fluctuations. 2. A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is A) "I must document and report any information." B) "I can’t make such a promise." C) "That depends on what you tell me." D) "I must report everything to the treatment team." B: "I can’t make such a promise." Secrets are inappropriate in therapeutic relationships and are counter productive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse honors and helps clients to understand rights, limitations, and boundaries regarding confidentiality. 3. The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)? A) Test blood sugar every 2 hours by Accu-Check B) Review with family and client signs of hyperglycemia C) Monitor for mental status changes D) Check skin condition of lower extremities A: Test blood sugar every 2 hours by Accu-Check. The UAP can do standard, unchanging procedures. 4. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with A) a Dopamine drip IV with vital signs monitored every 5 minutes B) a myocardial infarction that is free from pain and dysrhythmias C) a tracheotomy of 24 hours in some respiratory distress D) a pacemaker inserted this morning with intermittent capture B: A myocardial infarction that is free from pain and dysrhythmias. This client is the most stable with minimal risk of complications or instability. The nurse can utilize basic nursing skills to care for this client. 5. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)? A) Be with a client who self-administers insulin B) Cleanse and dress a small decubitus ulcer C) Monitor a client's response to passive range of motion exercises D) Apply and care for a client's rectal pouch D: Apply and care for a client''s rectal pouch. The RN may delegate the application and care of rectal pouches to a UAP. This is an uncomplicated, routine task. 6. The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees Fahrenheit for a post surgical client. The nurse checks on the client’s condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP? 23A) Encourage oral fluids to prevent dehydration B) Recheck temperature 15 minutes after removing hot liquids from the bedside C) Ask the client to drink only cold water and juices D) Chart this temperature elevation on the flow sheet B: Recheck temperature 15 minutes after removing hot liquids from the bedside. Recheck temperature to eliminate possible artificial elevation of temperature. Hot liquids, smoking, eating, chewing gum, and talking can all elevate temperature. Waiting to take the temperature for 15 minutes will help the temperature return to its normal, in order to get an accurate reading. Avoid premature assumptions about explanations for findings. The other options are incorrect. 7. A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)? A) To observe the type and amount of nasogastric tube drainage B) Monitor the client for nausea or other complications C) Irrigate the nasogastric tube with the ordered irrigant D) Perform nostril and mouth care D: Perform nostril and mouth care. Skin care around a nasogastric tube is a routine task that is appropriate for UAPs. The other tasks would be appropriate for a PN or RN to do since they are advanced skills or require evaluation. 8. A client asks the nurse to call the police and states: “I need to report that I am being abused by a nurse.” The nurse should first A) focus on reality orientation to place and person B) assist with the report of the client’s complaint to the police C) obtain more details of the client’s claim of abuse D) document the statement on the client’s chart with a report to the manager C: Obtain more details of the client’s claim of abuse. The advocacy role of the professional nurse as well as the legal duty of the reasonable prudent nurse requires the investigation of claims of abuse or violation of rights. The nurse is legally accountable for actions delegated to others. The application of the nursing process requires that the nurse gather more information, further assessment, before documentation or the reporting of the complaint. 9. When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because A) normal patterns of behavior may be labeled as deviant, immoral, or insane B) the meaning of the client's behavior can be derived from conventional wisdom C) personal values will guide the interaction between persons from 2 cultures D) the nurse should rely on her knowledge of different developmental mental stages A: Normal patterns of behavior may be labeled as deviant, immoral, or insane. Culture is an important variable in the assessment of individuals. To work effectively with clients, the nurse must be aware of a cultural distinctive qualities. 10. The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Assigning which of these tasks to a UAP indicates the student needs further teaching about the delegation process? A) Assist a client post cerebral vascular accident to ambulate B) Feed a 2 year-old in balanced skeletal traction C) Care for a client with discharge orders D) Collect a sputum specimen for acid fast bacillus C: Care for a client with discharge orders. A registered nurse (RN) is the best person to do teaching or evaluation that is needed at time of discharge. 11. The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client? A) Assign an RN to provide total care of the client B) Assign a nursing assistant to help the client with self-care activities C) Delegate complete care to an unlicensed assistive personnel D) Supervise a nursing assistant for skin care D: Supervise a nursing assistant for skin care. The nursing assistant can inspect the skin while giving hygiene care, but the nurse should supervise skin care since assessment and analysis are needed. 12. A client continuously calls out to the nursing staff when anyone passes the client’s door and asks them to do something in the room. The best response by the charge nurse would be to A) keep the client’s room door cracked to minimize the distractions B) assign 1 of the nursing staff to visit the client regularly C) reassure the client that 1 staff person will check frequently if the client needs anything D) arrange for each staff member to go into the client’s room to check on needs every hour on the hour B: Assign 1 of the nursing staff to visit the client regularly. Regular, frequent, planned contact by 1 staff member provides continuity of care and communicates to the client that care will be available when needed. 2413. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states “I don’t think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.” The nurse should understand that A) a referral is needed to the psychiatrist who is to provide the client with answers B) the client has a right to know about the prescribed medications C) such education is an independent decision of the individual nurse whether or not to teach clients about their medications D) clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects B: The client has a right to know about the prescribed medications. Clients have a right to informed consent which includes information about medications, treatments, and diagnostic studies. 14. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the practical nurse (PN)? A) Test a stool specimen for occult blood B) Assist with the ambulation of a client with a chest tube system C) Irrigate and redress a leg wound D) Admit a client from the emergency room C: Irrigate and redress a leg wound. The PN is a licensed provider and can perform this complex task. Options A and B could be delegated to an unlicensed assistive personnel (UAP), and option D requires an RN. 15. An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions? A) "How long have you been a UAP and what units you have worked on?" B) "What type of care do you give on the surgical unit and what ages of clients?" C) "What is your comfort level in caring for children and at what ages?" D) "Have you reviewed the list of expected skills you might need on this unit?" D: "Have you reviewed the list of expected skills you might need on this unit?". The UAP must be competent to accept the delegated task. Review of skills needed versus level of performance is the most efficient and effective way to determine this. 16. A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client’s mental status and adjustment. The appropriate response of the nurse should be which of these statements? A) "I am sorry. Referral information can only be provided by the client’s providers" B) "I can never give any information out by telephone. How do I know who you are?" C) "Since this is a referral, I can give you this information" D) "I need to get the client’s written consent before I release any information to you" D: In order to release information about a client there must be a signed consent form with designation of to whom information can be given, and what information can be shared. 17. A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse’s response should be to A) ask to not be assigned to this client or to work on another unit B) tell the client that such behavior is inappropriate C) inform the client that hospital policy prohibits staff to date clients D) discuss the boundaries of the therapeutic relationship with the client D: Discuss the boundaries of the therapeutic relationship with the client. The nurse-client relationship is one with professional not social boundaries. Consistent adherence to the limits of the professional relationship builds trust. 18. Which statement by the nurse is appropriate when directing an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time? A) "Have the client sit on the side of the bed for at least 2 minutes before helping him stand." B) "If the client is dizzy on standing, ask him to take some deep breaths." C) "Assist the client to the bathroom at least twice on this shift." D) "After you assist him to the chair, let me know how he feels." A: Give clear information to the UAP about what is expected for client safety. 19. After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can’t do anything that pleases him. I’m not going in there again." The nurse should respond by saying A) "He has a lot of problems. You need to have patience with him." B) "I will talk with him and try to figure out what to do." C) "He may be scared and taking it out on you. Let's talk to figure out what to do." D) "Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day." C: "He may be scared and taking it out on you. Let''s talk to figure out what to do." This response explains the client''s behavior without belittling the UAP’s feelings. The UAP is encouraged to contribute to the plan of care to help solve the problem. 20. A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP? 25A) A 76-year-old client with severe depression B) A middle-aged client with an obsessive compulsive disorder C) An adolescent with dehydration and anorexia D) A young adult who is a heroin addict in withdrawal with hallucinations - - - - - - - - - - - - - - - - - - - - - - - - - Priority 1. The nurse must know that the most accurate oxygen delivery system available is A) the Venturi mask B) nasal cannula C) partial non-rebreather mask D) simple face mask A: the Venturi mask. The most accurate way to deliver oxygen to the client is through a Venturi system such as the Venti Mask. The Venti Mask is a high flow device that entrains room air into a reservoir device on the mask and mixes the room air with 100% oxygen. The size of the opening to the reservoir determines the concentration of oxygen. The client’s respiratory rate and respiratory pattern do not affect the concentration of oxygen delivered. The maximum amount of oxygen that can be delivered by this system is 55%. 2. A client arrives in the emergency department after a radiologic accident at a local factory. The first action of the nurse would be to A) begin decontamination procedures for the client B) ensure physiologic stability of the client C) wrap the client in blankets to minimize staff contamination D) double bag the client’s contaminated clothing B: ensure physiologic stability of the client. The nurse must initially assist in stabilizing the patient prior to performing the other tasks related to radiologic contamination. 3. The nurse is caring for a client on complete bed rest. Which action by the nurse is most important in preventing the formation of deep vein thrombosis? A) Elevate the foot of the bed B) Apply knee high support stockings C) Encourage passive exercises D) Prevent pressure at back of knees D: Prevent pressure at back of knees. Preventing popliteal pressure will prevent venous stasis and possibly deep vein thrombosis. 4. If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is appropriate? A) Obtain emergency equipment B) Assess heart rate, rhythm and all pulses C) Apply pressure to the vessel insertion site D) Use cold packs at the exit incision site C: If a central venous catheter is accidentally removed, pressure should be applied to the vein entry site. 5. The nurse assesses several post partum women in the clinic. Which of the following women is at highest risk for puerperal infection? A) 12 hours post partum, temperature of 100.4 degrees Fahrenheit since delivery B) 2 days post partum, temperature of 101.2 degrees Fahrenheit this morning C) 3 days post partum, temperature of 100.8 degrees Fahrenheit the past 2 days D) 4 days post partum, temperature of 100 degrees Fahrenheit since delivery 30C: A temperature of 100.4 degrees Fahrenheit or higher on 2 successive days, not counting the first 24 hours after birth, indicates a post partum infection. 6. The nurse is caring for a client with a chest tube. On the second postoperative day, the chest tube accidentally disconnects from the drainage tube. The first action the nurse should take is A) reconnect the tube B) raise the collection chamber above the client's chest C) call the health care provider D) clamp the chest tube D: clamp the chest tube. Immediate steps should be taken to prevent air from entering the chest cavity. Lung collapse may occur if air enters the chest cavity. Clamping the tube close to the client’s chest is the first action to take, followed by health care provider notification. 7. A client is placed on sulfamethoxazole-trimethoprim (Bactrim) for a recurrent urinary tract infection. Which of the following is appropriate reinforcement of information by the nurse? A) "Drink at least 8 glasses of water a day." B) "Be sure to take the medication with food." C) "It is safe to take with oral contraceptives." D) "Stop the medication after 5 days." A: "Drink at least 8 glasses of water a day." Bactrim is a highly insoluble drug and requires a large volume of fluid intake. It is not necessary to take it with food. Options C and D are incorrect instructions for those taking Bactrim. 8. A client calls the evening health clinic to state “I know I have a severely low sugar since the Lantus insulin was given 3 hours ago and it peaks in 2 hours.” What should be the nurse’s initial response to the client? A) What else do you know about this type of insulin? B) What are you feeling at this moment? C) Have you eaten anything today? D) Are you taking any other insulin or medication? B: What are you feeling at this moment? When a client has changed from stable to unstable, the nurse’s initial response should be to do further assessment of the client. 9. The nurse is caring for a client who is receiving total parenteral nutrition (TPN) (hyperalimentation and lipids). What is the priority nursing action on every 8 hour shift? A) Monitor blood pressure, temperature and weight B) Change the tubing under sterile conditions C) Check urine glucose, acetone and specific gravity D) Adjust the infusion rate to provide for total volume C: Check urine glucose, acetone and specific gravity. Because of the high dextrose and protein content in parenteral nutrition, the nurse should assess the urine at least every 8 hours. 10. The nurse reviews an order to administer Rh (D) immune globulin to an Rh negative woman following the birth of an Rh positive baby. Which assessment is a priority before the nurse gives the injection? A) Newborn's blood type B) Coombs' test results C) Previous RhoGAM history D) Gravida and parity B: Coombs'' test results. Rh (D) immune globulin (RhoGAM) is given only if antibody formation has not occurred. A negative Coombs'' test confirms this. 11. A client has been on antibiotics for 72 hours for cystitis. Which report from the client requires priority attention by the nurse? A) foul smelling urine B) burning on urination C) elevated temperature D) nausea and anorexia C: elevated temperature. Elevated temperature after 72 hours on an antibiotic indicates the antibiotic has not been effective in eradicating the offending organism. The provider should be informed immediately so that an appropriate medication can be prescribed, and complications such as pyelonephritis are prevented. Options A and B are expected with cystitis. Option D may be related to the antibiotics as a side effect and should also be reported to the provider. 12. The nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism following treatment for chronic renal disease. Which of the following lab data should receive priority attention? A) Calcium and phosphorus levels B) Blood sugar C) Urine specific gravity 31D) Blood urea nitrogen A: Calcium and phosphorus levels. Calcium and phosphorous levels will be elevated until the client is stabilized. 13. When caring for a client with urinary incontinence, which content should be reinforced by the nurse? A) hold the urine to increase bladder capacity B) avoid eating foods high in sodium C) restrict fluid to prevent elimination accidents D) avoid taking antihistamines D: avoid taking antihistamines. Antihistamines can aggravate urinary incontinence and should be avoided by these clients. Holding the urine, avoiding sodium, and restricting fluids have not been shown to reduce urinary incontinence. 14. A client returns from the operating room after a right orchiectomy. For the immediate post-operative period the nursing priority would be to A) maintain fluid and electrolyte balance B) manage post-operative pain C) ambulate the client within 1 hour of surgery D) control bladder spasms B: manage post-operative pain. Due to the location of the incision, pain management is the priority. Bladder spasms are more related to prostate surgery. 15. A client with a fracture of the radius had a plaster cast applied 2 days ago. The client complains of constant pain and swelling of the fingers. The first action of the nurse should be A) elevate the arm no higher than heart level B) remove the cast C) assess capillary refill of the exposed hand and fingers D) apply a warm soak to the hand C: assess capillary refill of the exposed hand and fingers. A deterioration in neurovascular status indicates the development of compartment syndrome (elevated tissue pressure within a confined area) which requires immediate pressure-reducing interventions. 16. A client is 2 days post operative. The vital signs are: BP - 120/70, HR -- 110 BPM, RR - 26, and Temperature - 100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse first to the client's change in condition? A) Heart rate B) Respiratory rate C) Blood pressure D) Temperature B: Respiratory rate. Tachypnea is one of the first clues that the client is not oxygenating appropriately. The compensatory mechanism for decreased oxygenation is increased respiratory rate. 17. A client is waiting to have an intravenous pyelogram (IVP). The most important information to be obtained by the nurse prior to the procedure is A) time of the client's last meal B) client's allergy history C) assessment of the peripheral pulses D) results of the blood coagulation studies B: client''s allergy history. Intravenous Pyelogram is a dye study that uses an iodine-based contract. Therefore, the study is contraindicated in clients with allergy to iodine. 18. What must the nurse emphasize when teaching a client with depression about a new prescription for nortriptyline (Pamelor)? A) Symptom relief occurs in a few days B) Alcohol use is to be avoided C) Medication must be stored in the refrigerator D) Episodes of diarrhea can be expected B: Alcohol use is to be avoided. Alcohol potentiates the action of tricyclic antidepressants. 19. Before administering a feeding through a gastrostomy tube, what is the priority nursing assessment? A) Measure the vital signs B) Palpate the abdomen C) Assess for breath sounds D) Verify tube patency 32D: Verify tube patency. Tube patency should be checked prior to all feedings. The feeding should not be attempted if the tube is not patent. 20. The nurse is caring for a client with a vascular access for hemodialysis. Which of these findings necessitates immediate action by the nurse? A) pruritic rash B) dry, hacking cough C) chronic fatigue D) elevated temperature- - - - - [Show More]

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