NURSING 200comp A rationales (1).
1. A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis
of the left lower leg. Which of the following interventions should the nurse include in the plan
of care?
- Elevate the affected leg
- Rationale: the nurse should elevate the client’s affected extremity to reduce edema
and decrease the risk of chronic venous insufficiency
2. A nurse is teaching a group of guardians about child safety measures. Which of the
following statements by a guardian indicates an understanding of the teaching?
- I should have my child avoid sun exposure between 10 am and 2 pm
- Rationale: to prevent sunburns, guardians should apply sunscreen, dress their child in
protective clothing and avoid sun exposure between 1000 and 1400
3. A nurse is providing teaching about infection prevention to a client who has been receiving
chemotherapy. Which of the following statements by the client indicated an understanding
of the teaching?
- “I will walk for short distances throughout the day”
- Rationale: The client should ambulate for short distances as tolerated throughout the day.
This will help to reduce pulmonary stasis and prevent the development of respiratory
infections.
4. A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of
the following instructions should the nurse include?
- Introduce new foods one at a time over 5 to 7 days
- Rationale: The parent should introduce new foods one at a time over 5 to 7 days to
identify potential food allergies
5. A charge nurse is planning care for a client who has mechanical restraints in place. Which of
the following interventions should the nurse include in the plan of care?
- Provide a staff member to stay with the client continuously
- Rationale: a staff member must remain continuously with a client who is in restraints or view
the client via audiovisual equipment, if necessary, due to risk of injury.
6. A community health nurse is assisting with the development of a disaster management plan.
The nurse should include which of the following nursing responsibilities in the disaster response
stage of the plan?
- Performing a rapid needs assessment
- Rationale: disaster management includes prevention, preparedness, response, and recovery
stages. The nurse should perform a rapid needs assessment during the response phase of the
disaster cycle. A rapid needs assessment allows the nurse to identify the severity of the
incident, the health needs of the community, and the priority actions needed during the
response stage.
7. A nurse manager is assisting with the orientation of a newly licensed nurse. Which of
the following actions by the nurser requires the nurse manager to intervene?
- Tells the hospital chaplain a client’s diagnosis
- Rationale: discussing a client’s diagnosis with the hospital chaplain is a breach of
client confidentiality and a violation of HIPAA
8. A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage
of labor, the nurse observes early decelerations on the monitor tracing. Which of the following
actions should the nurse take?
- Continue observing the fetal heart rate
,NURSING 200comp A rationales (1).
- Rationale: early decelerations indicate the progression of labor and are an expected finding.
The nurse should monitor the fetus by observing the fetal heart rate and tracing.
9. A nurse manager is planning to make changes to the current scheduling system on the unit.
To facilitate the staff’s acceptance of this change, which of the following actions should the
nurse manager take first?
- Provide information about scheduling issues to the staff
- Rationale: the first stage of the change process is the unfreezing stage, when the nurse
should inform the staff about the current staffing issues. This can increase their
understanding of why the changes are necessary.
10. A nurse is planning teaching about allowable foods for a client who has a history of uric
acid- based urinary calculi formation. Which of the following foods should the nurse include
in the teaching?
- Oranges
- Rationale: a client who is prone to uric acid calculi formation can eat citrus fruits
11. A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of
the following should the nurse include in the teaching?
- The cervix transitions to an anterior position
- Rationale: in true labor the cervix transitions to an anterior position and begins to filate in
the preparation for birth.
12. A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure. Which of
the following findings should indicate to the nurse that the client has the ability to sign the
informed consent?
- The client is able to accurately describe the upcoming procedure
- Rationale: the ability of the client to accurately describe the upcoming procedure indicates
that the provider adequately informed the client, and that the client is able to sign the
informed consent form
13. A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The
nurse expresses concern about having limited experience with monitoring chest tube drainage.
Which of the following actions should the charge nurse take first to provide teaching about
chest tubes?
- Ask the nurse about their knowledge of the procedure
- Rationale: the first action the charge nurse should take nursing the nursing process is to assess
the newly licensed nurse’s knowledge about the procedure. By assessing the nurse’s
knowledge the charge nurse can identify the nurse’s learning needs.
14. A nurse is teaching a client who has a new prescription for estradiol. For which of the
following adverse effects of this medication should the nurse instruct the client to monitor
and report to the provider?
- Headaches
- Rationale: the nurse should instruct the client to monitor for and report headaches.
Headaches can be an indication of thromboembolic stroke because estradiol increases the risk
for adverse cardiovascular events.
15. Dosage problem: we already know this shi*
, NURSING 200comp A rationales (1).
16. A nurse is caring for a client who is 12 hours postoperative, is receiving PCA for pain control,
and requires a blood pressure check in 10 minutes. Which of the following staff members
should the nurse assign to collect this information?
- An assistive personnel (AP) who is assisting a client to return to bed
- Rationale: Performing a blood pressure check is within the range of function of an AP, and the
AP should be available to obtain a blood pressure within the specified time.
17. A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute
neutrophil count of 400/mm3. Which of the following interventions should the nurse include
in the plan?
- Withhold administering the varicella vaccine to the child
- Rationale: a child who has immunodeficiency should not receive a live vaccine due to the risk
of developing the disease. Inactivated vaccines can be administered to children who are
immunosuppressed.
18. A nurse is providing teaching about improving nutrition for a client who has multiple
sclerosis. Which of the following instructions should the nurse include? SATA
- A speech pathologist will be performing a swallowing study for you
- Rationale: the nurse should instruct the client that a swallowing study will be performed to
determine the client’s risk for aspiration due to difficulty swallowing, which is a manifestation
of multiple sclerosis.
- You should rest before eating a meal
- Rationale: The nurse should encourage the client to rest before each meal. Clients who
have multiple sclerosis often report weakness and are easily fatigued.
- Thicken your beverages before drinking
- Rationale: the nurse should instruct the client that liquids should be thickened to reduce the
risk of aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis.
19. A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of
the following findings is the priority for the nurse to report to the provider?
- Temperature 39.4 C (102.9 F)
- Rationale: the greatest risk to this client is injury from neuroleptic malignant syndrome, a
potentially life-threatening adverse effect of chlorpromazine that can cause the client to have
a high temperature, dysrhythmia, decreased level of consciousness, and a liable blood
pressure. Therefore, the priority finding for the nurse report to the provider is the fever.
20. A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and
a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse
anticipate administering?
- Flumazenil
- Rationale: The nurse should anticipate administering flumazenil, a competitive
benzodiazepine receptor antagonist to reverse the sedative effects of lorazepam. In addition,
the nurse should continue to support the client’s respirations with a bag-valve mask.
21. A nurse is caring for an older adult client in the PACU following general anesthesia. Which of
the following findings should the nurse report to the provider?
- Audible stridor
1. A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis
of the left lower leg. Which of the following interventions should the nurse include in the plan
of care?
- Elevate the affected leg
- Rationale: the nurse should elevate the client’s affected extremity to reduce edema
and decrease the risk of chronic venous insufficiency
2. A nurse is teaching a group of guardians about child safety measures. Which of the
following statements by a guardian indicates an understanding of the teaching?
- I should have my child avoid sun exposure between 10 am and 2 pm
- Rationale: to prevent sunburns, guardians should apply sunscreen, dress their child in
protective clothing and avoid sun exposure between 1000 and 1400
3. A nurse is providing teaching about infection prevention to a client who has been receiving
chemotherapy. Which of the following statements by the client indicated an understanding
of the teaching?
- “I will walk for short distances throughout the day”
- Rationale: The client should ambulate for short distances as tolerated throughout the day.
This will help to reduce pulmonary stasis and prevent the development of respiratory
infections.
4. A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of
the following instructions should the nurse include?
- Introduce new foods one at a time over 5 to 7 days
- Rationale: The parent should introduce new foods one at a time over 5 to 7 days to
identify potential food allergies
5. A charge nurse is planning care for a client who has mechanical restraints in place. Which of
the following interventions should the nurse include in the plan of care?
- Provide a staff member to stay with the client continuously
- Rationale: a staff member must remain continuously with a client who is in restraints or view
the client via audiovisual equipment, if necessary, due to risk of injury.
6. A community health nurse is assisting with the development of a disaster management plan.
The nurse should include which of the following nursing responsibilities in the disaster response
stage of the plan?
- Performing a rapid needs assessment
- Rationale: disaster management includes prevention, preparedness, response, and recovery
stages. The nurse should perform a rapid needs assessment during the response phase of the
disaster cycle. A rapid needs assessment allows the nurse to identify the severity of the
incident, the health needs of the community, and the priority actions needed during the
response stage.
7. A nurse manager is assisting with the orientation of a newly licensed nurse. Which of
the following actions by the nurser requires the nurse manager to intervene?
- Tells the hospital chaplain a client’s diagnosis
- Rationale: discussing a client’s diagnosis with the hospital chaplain is a breach of
client confidentiality and a violation of HIPAA
8. A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage
of labor, the nurse observes early decelerations on the monitor tracing. Which of the following
actions should the nurse take?
- Continue observing the fetal heart rate
,NURSING 200comp A rationales (1).
- Rationale: early decelerations indicate the progression of labor and are an expected finding.
The nurse should monitor the fetus by observing the fetal heart rate and tracing.
9. A nurse manager is planning to make changes to the current scheduling system on the unit.
To facilitate the staff’s acceptance of this change, which of the following actions should the
nurse manager take first?
- Provide information about scheduling issues to the staff
- Rationale: the first stage of the change process is the unfreezing stage, when the nurse
should inform the staff about the current staffing issues. This can increase their
understanding of why the changes are necessary.
10. A nurse is planning teaching about allowable foods for a client who has a history of uric
acid- based urinary calculi formation. Which of the following foods should the nurse include
in the teaching?
- Oranges
- Rationale: a client who is prone to uric acid calculi formation can eat citrus fruits
11. A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of
the following should the nurse include in the teaching?
- The cervix transitions to an anterior position
- Rationale: in true labor the cervix transitions to an anterior position and begins to filate in
the preparation for birth.
12. A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure. Which of
the following findings should indicate to the nurse that the client has the ability to sign the
informed consent?
- The client is able to accurately describe the upcoming procedure
- Rationale: the ability of the client to accurately describe the upcoming procedure indicates
that the provider adequately informed the client, and that the client is able to sign the
informed consent form
13. A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The
nurse expresses concern about having limited experience with monitoring chest tube drainage.
Which of the following actions should the charge nurse take first to provide teaching about
chest tubes?
- Ask the nurse about their knowledge of the procedure
- Rationale: the first action the charge nurse should take nursing the nursing process is to assess
the newly licensed nurse’s knowledge about the procedure. By assessing the nurse’s
knowledge the charge nurse can identify the nurse’s learning needs.
14. A nurse is teaching a client who has a new prescription for estradiol. For which of the
following adverse effects of this medication should the nurse instruct the client to monitor
and report to the provider?
- Headaches
- Rationale: the nurse should instruct the client to monitor for and report headaches.
Headaches can be an indication of thromboembolic stroke because estradiol increases the risk
for adverse cardiovascular events.
15. Dosage problem: we already know this shi*
, NURSING 200comp A rationales (1).
16. A nurse is caring for a client who is 12 hours postoperative, is receiving PCA for pain control,
and requires a blood pressure check in 10 minutes. Which of the following staff members
should the nurse assign to collect this information?
- An assistive personnel (AP) who is assisting a client to return to bed
- Rationale: Performing a blood pressure check is within the range of function of an AP, and the
AP should be available to obtain a blood pressure within the specified time.
17. A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute
neutrophil count of 400/mm3. Which of the following interventions should the nurse include
in the plan?
- Withhold administering the varicella vaccine to the child
- Rationale: a child who has immunodeficiency should not receive a live vaccine due to the risk
of developing the disease. Inactivated vaccines can be administered to children who are
immunosuppressed.
18. A nurse is providing teaching about improving nutrition for a client who has multiple
sclerosis. Which of the following instructions should the nurse include? SATA
- A speech pathologist will be performing a swallowing study for you
- Rationale: the nurse should instruct the client that a swallowing study will be performed to
determine the client’s risk for aspiration due to difficulty swallowing, which is a manifestation
of multiple sclerosis.
- You should rest before eating a meal
- Rationale: The nurse should encourage the client to rest before each meal. Clients who
have multiple sclerosis often report weakness and are easily fatigued.
- Thicken your beverages before drinking
- Rationale: the nurse should instruct the client that liquids should be thickened to reduce the
risk of aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis.
19. A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of
the following findings is the priority for the nurse to report to the provider?
- Temperature 39.4 C (102.9 F)
- Rationale: the greatest risk to this client is injury from neuroleptic malignant syndrome, a
potentially life-threatening adverse effect of chlorpromazine that can cause the client to have
a high temperature, dysrhythmia, decreased level of consciousness, and a liable blood
pressure. Therefore, the priority finding for the nurse report to the provider is the fever.
20. A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and
a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse
anticipate administering?
- Flumazenil
- Rationale: The nurse should anticipate administering flumazenil, a competitive
benzodiazepine receptor antagonist to reverse the sedative effects of lorazepam. In addition,
the nurse should continue to support the client’s respirations with a bag-valve mask.
21. A nurse is caring for an older adult client in the PACU following general anesthesia. Which of
the following findings should the nurse report to the provider?
- Audible stridor
