A nurse who has recently completed orientation is beginning work in the labor and
delivery unit for the first time. When making assignments, which client should the
charge nurse assign to this new nurse?
A.A primigravida who is 8 cm dilated after 14 hours of labor
B.A client scheduled for a repeat cesarean birth at 38 weeks' gestation
C.A client being induced for fetal demise at 20 weeks' gestation
D.A multiparous client who is dilated 5 cm and 50% effaced
D
The new nurse should be assigned the least complicated client to gain experience and
confidence, as well as protect client safety. Of the clients available for assignment, (D)
is progressing well and is the least complicated. (A, B and C) have actual or potential
complications and should be assigned to a more experienced nurse.
A client with human immunodeficiency virus (HIV) infection has white lesions in the oral
cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a
swish and swallow. Which information is most important for the nurse to provide the
client?
A.Oral hygiene should be performed before the medication. B.Antifungal medications
are available in tablet, suppository, and liquid forms.
C.Candida albicans is the organism that causes the white lesions in the mouth.
D.The dietary intake of dairy and spicy foods should be limited.
A
HIV infection causes depression of cell-mediated immunity that allows an overgrowth of
Candida albicans (oral moniliasis), which appears as white, cheesy plaque or lesions
that resemble milk curds. To ensure effective contact of the medication with the oral
lesions, oral liquids should be consumed and oral hygiene performed before swishing
the liquid Mycostatin (A). (B and C) provide the client with additional information about
the pathogenesis and treatment of opportunistic infections, but (A) allows the client to
participate in self-care of the oral infection. Dietary restriction of spicy foods reduces
discomfort associated with stomatitis, but restriction of dairy products is not indicated
(D).
A client who is admitted with emphysema is having difficulty breathing. In which position
should the nurse place the client?
A.High Fowler's position without a pillow behind the head
B.Semi-Fowler's position with a single pillow behind the head
C.Right side-lying position with the head of the bed elevated 45 degrees
D.Sitting upright and forward with both arms supported on an over the bed table
D
Adequate lung expansion is dependent on deep breaths that allow the respiratory
muscles to increase the longitudinal and anterior-posterior size of the thoracic cage.
Sitting upright and leaning forward with the arms supported on an over the bed table (D)
allows the thoracic cage to expand in all four directions and reduces dyspnea. A high
Fowler's position does not allow maximum expansion of the posterior lobes of the lungs
(A). A semi-Fowler's position restricts expansion of the anterior-posterior diameter of the
,thoracic cage (B). Positioning a client on the right side with the head of the bed elevated
(C) does not facilitate lung expansion.
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide
(HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the
client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's
potassium level?
A.The client is noncompliant with his medications.
B.The client recently consumed large quantities of pears or nuts.
C.The client's renal function has affected his potassium level.
D.The client needs to be started on a potassium supplement.
C
The client has a normalized potassium level despite diuretic use (C). The kidney
automatically secretes 90% of potassium consumed, but in chronic renal insufficiency
(CRI), less potassium is excreted than normal. Therefore, the two potassium-wasting
drugs, a thiazide diuretic and loop diuretic, are not likely to affect potassium levels. The
normal potassium level is 3.5 to 5 mEq/L, and with a potassium level of 4 mEq/L, there
is no reason to believe that the client is noncompliant with his treatment (A). Pears and
nuts do not affect the serum potassium level (B). There is no need for a potassium
supplement (D) because the client's potassium level is within the normal range.
A registered nurse (RN) delivers telehealth services to clients via electronic
communication. Which nursing action creates the greatest risk for professional liability
and has the potential for a malpractice lawsuit?
A.Participating in telephone consultations with clients
B.Identifying oneself by name and title to clients in telehealth communications
C.Sending medical records to health care providers via the Internet
D.Answering a client-initiated health question via electronic mail
C
Sending medical records over the Internet, even with the latest security protection,
creates the greatest risk for liability because of the high potential of breaching client
confidentiality and the amount of information being transferred (C). Client confidentiality
is protected by federal wiretapping laws making telephone consultation (A) a private and
protected form of communication. By stating one's name and credentials in telehealth
communication (B), one is taking responsibility for the encounter. E-mail initiated by the
client (D) poses less risk than sending records via the Internet.
Which pathophysiologic response supports the contraindication for opioids, such as
morphine, in clients with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is
elevated.
B.Higher doses of opioids are required when cerebral blood flow is reduced by an
elevated ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with an
elevated ICP.
,D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated
ICP.
D
The greatest risk associated with opioids such as morphine (D) is respiratory
depression that causes an increase in Pco2, which increases ICP and masks the early
signs of intracranial bleeding in head injury. (A, B, and C) do not support the risks
associated with opioid use in a client with increased ICP.
The charge nurse of a medical surgical unit is alerted to an impending disaster requiring
implementation of the hospital's disaster plan. Specific facts about the nature of this
disaster are not yet known. Which instruction should the charge nurse give to the other
staff members at this time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
D.Continue with current assignments until more instructions are received.
D
When faced with an impending disaster, hospital personnel may be alerted but should
continue with current client care assignments until further instructions are received (D).
Evacuation is typically a response of last resort that begins with clients who are most
able to ambulate (A). (B) is premature and is likely to increase the chaos if incoming
casualties are anticipated. (C) is poor utilization of personnel.
The nurse assesses a client while the UAP measures the client's vital signs. The client's
vital signs change suddenly, and the nurse determines that the client's condition is
worsening. The nurse is unsure of the client's resuscitative status and needs to check
the client's medical record for any advanced directives. Which action should the nurse
implement?
A.Ask the UAP to check for the advanced directive while the nurse completes the
assessment.
B.Assign the UAP to complete the assessment while the nurse checks for the advanced
directive.
C.Check the medical record for the advanced directive and then complete the client
assessment.
D.Call for the charge nurse to check the advanced directive while continuing to assess
the client.
D
Because the client's condition is worsening, the nurse should remain with the client and
continue the assessment while calling for help from the charge nurse to determine the
client's resuscitative status (D). (A and B) are tasks that must be completed by a nurse
and cannot be delegated to the UAP. (C) is contraindicated.
The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the
nurse. Which task is important for the nurse to perform, rather than the UAP?
A.Remove the client's nail polish and dentures.
B.Assist the client to the restroom to void.
, C.Obtain the client's height and weight.
D.Offer the client emotional support.
D
By using therapeutic techniques to offer support (D), the nurse can determine any client
concerns that need to be addressed. (A, B, and C) are all actions that can be performed
by the UAP under the supervision of the nurse.
Until the census on the obstetrics (OB) unit increases, an unlicensed assistive
personnel (UAP) who usually works in labor and delivery and the newborn nursery is
assigned to work on the postoperative unit. Which client would be best for the charge
nurse to assign to this UAP?
A.An adolescent who was readmitted to the hospital because of a postoperative
infection
B.A woman with a new colostomy who requires discharge teaching
C.A woman who had a hip replacement and may be transferred to the home care unit
D.A man who had a cholecystectomy and currently has a nasogastric tube set to
intermittent suction
C
The charge nurse will be responsible for providing a report to the home care unit if the
transfer occurs (A). The client is infected and an employee who works on an OB unit
should be assigned to clean cases in case the employee is required to return to the OB
unit (B). This requires the skills of a registered nurse (RN) to do discharge teaching and
provide emotional support (D). This may require skills beyond the level of this UAP.
A male client is admitted for observation after being hit on the head with a baseball bat.
Six hours after admission, the client attempts to crawl out of bed and asks the nurse
why there are so many bugs in his bed. His vital signs are stable, and the pulse
oximeter reading is 98% on room air. Which intervention should the nurse perform first?
A.Administer oxygen per nasal cannula at 2 L/min.
B.Plan to check his vital signs again in 30 minutes.
C.Notify the health care provider of the change in mental status.
D.Ask the client why he thinks there are bugs in the bed.
C
One of the earliest signs of increased intracranial pressure (ICP) is a change in mental
status (C). It is important to act early and quickly when symptoms of increased ICP
occur. Because his oxygen saturation is normal, the administration of oxygen (A) is not
the top priority. Vital signs should be monitored frequently (B), but the client's confusion
should be reported immediately. (D) is not a useful intervention.
The nurse is monitoring a client who is receiving bedside conscious sedation with
midazolam hydrochloride (Versed). In assessing the client, the nurse determines that
the client has slurred speech with diplopia. Based on this finding, what action should the
nurse take?
A.Open the airway with a chin lift-head tilt maneuver.
B.Obtain a fingerstick glucose reading.
delivery unit for the first time. When making assignments, which client should the
charge nurse assign to this new nurse?
A.A primigravida who is 8 cm dilated after 14 hours of labor
B.A client scheduled for a repeat cesarean birth at 38 weeks' gestation
C.A client being induced for fetal demise at 20 weeks' gestation
D.A multiparous client who is dilated 5 cm and 50% effaced
D
The new nurse should be assigned the least complicated client to gain experience and
confidence, as well as protect client safety. Of the clients available for assignment, (D)
is progressing well and is the least complicated. (A, B and C) have actual or potential
complications and should be assigned to a more experienced nurse.
A client with human immunodeficiency virus (HIV) infection has white lesions in the oral
cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a
swish and swallow. Which information is most important for the nurse to provide the
client?
A.Oral hygiene should be performed before the medication. B.Antifungal medications
are available in tablet, suppository, and liquid forms.
C.Candida albicans is the organism that causes the white lesions in the mouth.
D.The dietary intake of dairy and spicy foods should be limited.
A
HIV infection causes depression of cell-mediated immunity that allows an overgrowth of
Candida albicans (oral moniliasis), which appears as white, cheesy plaque or lesions
that resemble milk curds. To ensure effective contact of the medication with the oral
lesions, oral liquids should be consumed and oral hygiene performed before swishing
the liquid Mycostatin (A). (B and C) provide the client with additional information about
the pathogenesis and treatment of opportunistic infections, but (A) allows the client to
participate in self-care of the oral infection. Dietary restriction of spicy foods reduces
discomfort associated with stomatitis, but restriction of dairy products is not indicated
(D).
A client who is admitted with emphysema is having difficulty breathing. In which position
should the nurse place the client?
A.High Fowler's position without a pillow behind the head
B.Semi-Fowler's position with a single pillow behind the head
C.Right side-lying position with the head of the bed elevated 45 degrees
D.Sitting upright and forward with both arms supported on an over the bed table
D
Adequate lung expansion is dependent on deep breaths that allow the respiratory
muscles to increase the longitudinal and anterior-posterior size of the thoracic cage.
Sitting upright and leaning forward with the arms supported on an over the bed table (D)
allows the thoracic cage to expand in all four directions and reduces dyspnea. A high
Fowler's position does not allow maximum expansion of the posterior lobes of the lungs
(A). A semi-Fowler's position restricts expansion of the anterior-posterior diameter of the
,thoracic cage (B). Positioning a client on the right side with the head of the bed elevated
(C) does not facilitate lung expansion.
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide
(HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the
client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's
potassium level?
A.The client is noncompliant with his medications.
B.The client recently consumed large quantities of pears or nuts.
C.The client's renal function has affected his potassium level.
D.The client needs to be started on a potassium supplement.
C
The client has a normalized potassium level despite diuretic use (C). The kidney
automatically secretes 90% of potassium consumed, but in chronic renal insufficiency
(CRI), less potassium is excreted than normal. Therefore, the two potassium-wasting
drugs, a thiazide diuretic and loop diuretic, are not likely to affect potassium levels. The
normal potassium level is 3.5 to 5 mEq/L, and with a potassium level of 4 mEq/L, there
is no reason to believe that the client is noncompliant with his treatment (A). Pears and
nuts do not affect the serum potassium level (B). There is no need for a potassium
supplement (D) because the client's potassium level is within the normal range.
A registered nurse (RN) delivers telehealth services to clients via electronic
communication. Which nursing action creates the greatest risk for professional liability
and has the potential for a malpractice lawsuit?
A.Participating in telephone consultations with clients
B.Identifying oneself by name and title to clients in telehealth communications
C.Sending medical records to health care providers via the Internet
D.Answering a client-initiated health question via electronic mail
C
Sending medical records over the Internet, even with the latest security protection,
creates the greatest risk for liability because of the high potential of breaching client
confidentiality and the amount of information being transferred (C). Client confidentiality
is protected by federal wiretapping laws making telephone consultation (A) a private and
protected form of communication. By stating one's name and credentials in telehealth
communication (B), one is taking responsibility for the encounter. E-mail initiated by the
client (D) poses less risk than sending records via the Internet.
Which pathophysiologic response supports the contraindication for opioids, such as
morphine, in clients with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is
elevated.
B.Higher doses of opioids are required when cerebral blood flow is reduced by an
elevated ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with an
elevated ICP.
,D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated
ICP.
D
The greatest risk associated with opioids such as morphine (D) is respiratory
depression that causes an increase in Pco2, which increases ICP and masks the early
signs of intracranial bleeding in head injury. (A, B, and C) do not support the risks
associated with opioid use in a client with increased ICP.
The charge nurse of a medical surgical unit is alerted to an impending disaster requiring
implementation of the hospital's disaster plan. Specific facts about the nature of this
disaster are not yet known. Which instruction should the charge nurse give to the other
staff members at this time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
D.Continue with current assignments until more instructions are received.
D
When faced with an impending disaster, hospital personnel may be alerted but should
continue with current client care assignments until further instructions are received (D).
Evacuation is typically a response of last resort that begins with clients who are most
able to ambulate (A). (B) is premature and is likely to increase the chaos if incoming
casualties are anticipated. (C) is poor utilization of personnel.
The nurse assesses a client while the UAP measures the client's vital signs. The client's
vital signs change suddenly, and the nurse determines that the client's condition is
worsening. The nurse is unsure of the client's resuscitative status and needs to check
the client's medical record for any advanced directives. Which action should the nurse
implement?
A.Ask the UAP to check for the advanced directive while the nurse completes the
assessment.
B.Assign the UAP to complete the assessment while the nurse checks for the advanced
directive.
C.Check the medical record for the advanced directive and then complete the client
assessment.
D.Call for the charge nurse to check the advanced directive while continuing to assess
the client.
D
Because the client's condition is worsening, the nurse should remain with the client and
continue the assessment while calling for help from the charge nurse to determine the
client's resuscitative status (D). (A and B) are tasks that must be completed by a nurse
and cannot be delegated to the UAP. (C) is contraindicated.
The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the
nurse. Which task is important for the nurse to perform, rather than the UAP?
A.Remove the client's nail polish and dentures.
B.Assist the client to the restroom to void.
, C.Obtain the client's height and weight.
D.Offer the client emotional support.
D
By using therapeutic techniques to offer support (D), the nurse can determine any client
concerns that need to be addressed. (A, B, and C) are all actions that can be performed
by the UAP under the supervision of the nurse.
Until the census on the obstetrics (OB) unit increases, an unlicensed assistive
personnel (UAP) who usually works in labor and delivery and the newborn nursery is
assigned to work on the postoperative unit. Which client would be best for the charge
nurse to assign to this UAP?
A.An adolescent who was readmitted to the hospital because of a postoperative
infection
B.A woman with a new colostomy who requires discharge teaching
C.A woman who had a hip replacement and may be transferred to the home care unit
D.A man who had a cholecystectomy and currently has a nasogastric tube set to
intermittent suction
C
The charge nurse will be responsible for providing a report to the home care unit if the
transfer occurs (A). The client is infected and an employee who works on an OB unit
should be assigned to clean cases in case the employee is required to return to the OB
unit (B). This requires the skills of a registered nurse (RN) to do discharge teaching and
provide emotional support (D). This may require skills beyond the level of this UAP.
A male client is admitted for observation after being hit on the head with a baseball bat.
Six hours after admission, the client attempts to crawl out of bed and asks the nurse
why there are so many bugs in his bed. His vital signs are stable, and the pulse
oximeter reading is 98% on room air. Which intervention should the nurse perform first?
A.Administer oxygen per nasal cannula at 2 L/min.
B.Plan to check his vital signs again in 30 minutes.
C.Notify the health care provider of the change in mental status.
D.Ask the client why he thinks there are bugs in the bed.
C
One of the earliest signs of increased intracranial pressure (ICP) is a change in mental
status (C). It is important to act early and quickly when symptoms of increased ICP
occur. Because his oxygen saturation is normal, the administration of oxygen (A) is not
the top priority. Vital signs should be monitored frequently (B), but the client's confusion
should be reported immediately. (D) is not a useful intervention.
The nurse is monitoring a client who is receiving bedside conscious sedation with
midazolam hydrochloride (Versed). In assessing the client, the nurse determines that
the client has slurred speech with diplopia. Based on this finding, what action should the
nurse take?
A.Open the airway with a chin lift-head tilt maneuver.
B.Obtain a fingerstick glucose reading.
