Question 1 See full question
Several hours into a shift, a nurse on a very busy medical-surgical unit privately asks the
charge nurse to change her assignment. She is frustrated because she has had todevote so much
time and energy to helping a newly licensed nurse provide discharge teaching for clients with
diabetes mellitus. The charge nurse should:
Correct Answer:
• offer to assist with the discharge teaching needs.
Explanation:
Staff members need to know the charge nurse is a supportive leader who respects theirhonesty
and stands behind them. By offering to help with discharge teaching, the charge nurse is
actively engaging with her staff at a time of need. Changing all the assignments on this
extremely busy floor would be counterproductive. Insisting that the staff member follow
through with her assignment disrespects her request and genuine need. Providing a float nurse
could help, but there are no guarantees a float nurse is available.
Remediation:
• Discharge
Question 2 See full question
During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous
membrane related to decreased nutrition and immunosuppression secondaryto the cytotoxic
effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of
stomatitis
Correct Answer:
• Providing a solution of viscous lidocaine for use as a mouth rinse
Explanation:
To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen viscous
lidocaine for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain
alcohol and may cause dryness and irritation of the oral mucosa.)The nurse also may administer
systemic analgesics as ordered. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus,
stopping chemotherapy wouldn't be helpful or practical. Instead, the nurse should stay alert for
this potential problem to ensure prompttreatment. Monitoring platelet and leukocyte counts may
help prevent bleeding and infection but wouldn't decrease pain in this highly susceptible client.
Checking for signs and symptoms of stomatitis also wouldn't decrease the pain.
Remediation:
, • Impaired Oral Membrane
Question 3 See full question
A nurse has been caring for an adolescent client in a residential facility. The child has been
through a series of foster placements since infancy with no success in any placement until the
age of 7 when placed with a middle-aged single woman. The clientthrived there until the
woman was killed in a car accident. The client attempted suicideafter her foster mother died in
response to the loss and the child was placed in the residential facility. The nurse has become
close to this client and wants to help her address her issues and move on with her life. Which
comment to the manager demonstrates that the nurse understands the client’s issues and is able
to respond appropriately to the client’s needs?
You Selected:
• "It is difficult for her to love and trust again after her losses. In this facility, she can
learn to deal with her loss in a less emotionally charged environment than afoster
home."
Explanation:
The severe emotional trauma the girl has experienced will likely make it difficult for her to be
successful in an adoptive placement at the present time, whether that placement is with someone
she knows (the nurse) or another adoptive family. Additionally, adoptionby the nurse is
inappropriate because it blurs the lines between her professional and personal life and is likely to
confuse the client. It is clear that the client has many issues and that love alone is not likely to
solve all her problems. Treatment at the residential facility will allow her to work through
emotional issues in a more therapeutic environment. Though not currently ready for adoption,
she may be ready for adoption in the future after sufficient treatment.
Question 4 See full question
A client is about to undergo cardiac catheterization for which he signed an informed consent.
As the nurse enters the room to administer sedation for the procedure, the client states, "I'm
really worried about having this open heart surgery." Based on thisstatement, how should the
nurse proceed?
Correct Answer:
• Withhold the medication and notify the physician immediately.
Explanation:
The nurse should withhold the medication and notify the physician that the client does not
understand the procedure. The physician then has the obligation to explain the procedure better
to the client and determine whether or not the client understands. If theclient does not
understand, he cannot give a true informed consent. If the medication is administered before the
physician explains the procedure, the sedation may interfere
,with the client's ability to clearly understand the procedure. The nurse may not just medicate
the client and document the finding; the physician must be notified. The procedure does not
need to be cancelled, only postponed until the client receives moreeducation and is able to give
informed consent.
Remediation:
• Decisional Conflict
Question 5 See full question
Which action associated with restraint use on a confused client can be delegated to anunlicensed
healthcare worker/nursing assistant?
• Completion of range of motion on limbs restrained
Question 1 See full question
Four clients have been admitted to the cardiac intensive care unit after experiencingacute
myocardial infarctions. Each client has sustained a percentage of cardiac damage. Which client
is most in need of interventions to prevent the development ofcardiogenic shock?
Correct Answer:
• The client with 40% damage
Explanation:
At least 40% of the heart muscle must be involved for cardiogenic shock to develop. Inmost
circumstances, the heart can compensate for up to 25% damage. An infarction involving 70% of
the heart would have likely already caused cardiogenic shock.
Question 2 See full question
The nurse is providing postoperative care to a client with sickle cell anemia. What is themost
important intervention for the nurse to include in the plan of care?
Correct Answer:
• Increasing fluids
Explanation:
The main surgical risk of anesthesia is hypoxia. Emotional stress, demands of woundhealing,
and the potential for infection can each increase the sickling phenomenon.
Increased fluids are encouraged because hydration promotes hemodilution, and decreases
sickling. Preparing the child psychologically to decrease fear will minimize undue emotional
stress, but is not a priority. Deep coughing is encouraged to promotepulmonary hygiene and
prevent respiratory tract infection. Analgesics are used to control wound pain and to prevent
abdominal splinting and decreased ventilation.
, Remediation:
A hospitalized client, with a productive cough, chills, and night sweats is suspected ofhaving
active tuberculosis (TB). What is the nurse’s most important intervention?
You Selected:
• Maintain the client on respiratory isolation
Correct Answer:
• Maintain the client on respiratory isolation
Explanation:
This client is showing signs and symptoms of active TB and, because of the productivecough,
is highly contagious. He should be admitted to the hospital and placed in respiratory isolation.
Three sputum cultures should be obtained to confirm the diagnosis.
Question 4 See full question
The nurse is caring for a client with type 1 diabetes mellitus. At 3:00 AM, the nurse findsthe client
disoriented to time and place, diaphoretic, and complaining of palpitations.
What is the nurse’s priority intervention?
You Selected:
• Check blood glucose level
Correct Answer:
• Check blood glucose level
Explanation:
Check the blood glucose level first when symptoms arise, then proceed with treatmentaccording
to the results. If the client is hypoglycemic, administration of a simple carbohydrate is
appropriate. If the client is conscious, the carbohydrate may be given orally. If consciousness is
altered, subcutaneous or intramuscular glucagon is appropriate. This client is showing symptoms
of hypoglycemia, additional insulin wouldfurther lower the blood glucose.
Remediation:
• Diabetes Mellitus (Type 1), Long-Term Care
Question 5 See full question
A two-month-old infant arrives with a heart rate of 180 bpm and a temperature of 103.1°F
(39.5° C) rectally. What is the most appropriate initial nursing intervention?
Several hours into a shift, a nurse on a very busy medical-surgical unit privately asks the
charge nurse to change her assignment. She is frustrated because she has had todevote so much
time and energy to helping a newly licensed nurse provide discharge teaching for clients with
diabetes mellitus. The charge nurse should:
Correct Answer:
• offer to assist with the discharge teaching needs.
Explanation:
Staff members need to know the charge nurse is a supportive leader who respects theirhonesty
and stands behind them. By offering to help with discharge teaching, the charge nurse is
actively engaging with her staff at a time of need. Changing all the assignments on this
extremely busy floor would be counterproductive. Insisting that the staff member follow
through with her assignment disrespects her request and genuine need. Providing a float nurse
could help, but there are no guarantees a float nurse is available.
Remediation:
• Discharge
Question 2 See full question
During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous
membrane related to decreased nutrition and immunosuppression secondaryto the cytotoxic
effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of
stomatitis
Correct Answer:
• Providing a solution of viscous lidocaine for use as a mouth rinse
Explanation:
To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen viscous
lidocaine for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain
alcohol and may cause dryness and irritation of the oral mucosa.)The nurse also may administer
systemic analgesics as ordered. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus,
stopping chemotherapy wouldn't be helpful or practical. Instead, the nurse should stay alert for
this potential problem to ensure prompttreatment. Monitoring platelet and leukocyte counts may
help prevent bleeding and infection but wouldn't decrease pain in this highly susceptible client.
Checking for signs and symptoms of stomatitis also wouldn't decrease the pain.
Remediation:
, • Impaired Oral Membrane
Question 3 See full question
A nurse has been caring for an adolescent client in a residential facility. The child has been
through a series of foster placements since infancy with no success in any placement until the
age of 7 when placed with a middle-aged single woman. The clientthrived there until the
woman was killed in a car accident. The client attempted suicideafter her foster mother died in
response to the loss and the child was placed in the residential facility. The nurse has become
close to this client and wants to help her address her issues and move on with her life. Which
comment to the manager demonstrates that the nurse understands the client’s issues and is able
to respond appropriately to the client’s needs?
You Selected:
• "It is difficult for her to love and trust again after her losses. In this facility, she can
learn to deal with her loss in a less emotionally charged environment than afoster
home."
Explanation:
The severe emotional trauma the girl has experienced will likely make it difficult for her to be
successful in an adoptive placement at the present time, whether that placement is with someone
she knows (the nurse) or another adoptive family. Additionally, adoptionby the nurse is
inappropriate because it blurs the lines between her professional and personal life and is likely to
confuse the client. It is clear that the client has many issues and that love alone is not likely to
solve all her problems. Treatment at the residential facility will allow her to work through
emotional issues in a more therapeutic environment. Though not currently ready for adoption,
she may be ready for adoption in the future after sufficient treatment.
Question 4 See full question
A client is about to undergo cardiac catheterization for which he signed an informed consent.
As the nurse enters the room to administer sedation for the procedure, the client states, "I'm
really worried about having this open heart surgery." Based on thisstatement, how should the
nurse proceed?
Correct Answer:
• Withhold the medication and notify the physician immediately.
Explanation:
The nurse should withhold the medication and notify the physician that the client does not
understand the procedure. The physician then has the obligation to explain the procedure better
to the client and determine whether or not the client understands. If theclient does not
understand, he cannot give a true informed consent. If the medication is administered before the
physician explains the procedure, the sedation may interfere
,with the client's ability to clearly understand the procedure. The nurse may not just medicate
the client and document the finding; the physician must be notified. The procedure does not
need to be cancelled, only postponed until the client receives moreeducation and is able to give
informed consent.
Remediation:
• Decisional Conflict
Question 5 See full question
Which action associated with restraint use on a confused client can be delegated to anunlicensed
healthcare worker/nursing assistant?
• Completion of range of motion on limbs restrained
Question 1 See full question
Four clients have been admitted to the cardiac intensive care unit after experiencingacute
myocardial infarctions. Each client has sustained a percentage of cardiac damage. Which client
is most in need of interventions to prevent the development ofcardiogenic shock?
Correct Answer:
• The client with 40% damage
Explanation:
At least 40% of the heart muscle must be involved for cardiogenic shock to develop. Inmost
circumstances, the heart can compensate for up to 25% damage. An infarction involving 70% of
the heart would have likely already caused cardiogenic shock.
Question 2 See full question
The nurse is providing postoperative care to a client with sickle cell anemia. What is themost
important intervention for the nurse to include in the plan of care?
Correct Answer:
• Increasing fluids
Explanation:
The main surgical risk of anesthesia is hypoxia. Emotional stress, demands of woundhealing,
and the potential for infection can each increase the sickling phenomenon.
Increased fluids are encouraged because hydration promotes hemodilution, and decreases
sickling. Preparing the child psychologically to decrease fear will minimize undue emotional
stress, but is not a priority. Deep coughing is encouraged to promotepulmonary hygiene and
prevent respiratory tract infection. Analgesics are used to control wound pain and to prevent
abdominal splinting and decreased ventilation.
, Remediation:
A hospitalized client, with a productive cough, chills, and night sweats is suspected ofhaving
active tuberculosis (TB). What is the nurse’s most important intervention?
You Selected:
• Maintain the client on respiratory isolation
Correct Answer:
• Maintain the client on respiratory isolation
Explanation:
This client is showing signs and symptoms of active TB and, because of the productivecough,
is highly contagious. He should be admitted to the hospital and placed in respiratory isolation.
Three sputum cultures should be obtained to confirm the diagnosis.
Question 4 See full question
The nurse is caring for a client with type 1 diabetes mellitus. At 3:00 AM, the nurse findsthe client
disoriented to time and place, diaphoretic, and complaining of palpitations.
What is the nurse’s priority intervention?
You Selected:
• Check blood glucose level
Correct Answer:
• Check blood glucose level
Explanation:
Check the blood glucose level first when symptoms arise, then proceed with treatmentaccording
to the results. If the client is hypoglycemic, administration of a simple carbohydrate is
appropriate. If the client is conscious, the carbohydrate may be given orally. If consciousness is
altered, subcutaneous or intramuscular glucagon is appropriate. This client is showing symptoms
of hypoglycemia, additional insulin wouldfurther lower the blood glucose.
Remediation:
• Diabetes Mellitus (Type 1), Long-Term Care
Question 5 See full question
A two-month-old infant arrives with a heart rate of 180 bpm and a temperature of 103.1°F
(39.5° C) rectally. What is the most appropriate initial nursing intervention?
