An elderly client with a fractured left hip is on strict bedrest.
Which nursing measure is essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position.
To avoid shearing forces when repositioning, the client should be
lifted gently across a surface (D). Reddened areas should not be
massaged (A) since this may increase the damage to already
traumatized skin. To control pain and muscle spasms, active
range of motion (B) may be limited on the affected leg. The
position described in (C) is contraindicated for a client with a
fractured left hip.
Correct Answer: D
The nurse is administering medications through a nasogastric
tube (NGT) which is connected to suction. After ensuring
correct tube placement, what action should the nurse take
next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water.
The NGT should be flushed before, after and in between each
medication administered (B). Once all medications are
administered, the NGT should be clamped for 20 minutes (A). (C
and D) may be implemented only after the tubing has been
flushed.
Correct Answer: B
A client who is in hospice care complains of increasing
amounts of pain. The healthcare provider prescribes an
analgesic every four hours as needed. Which action should the
nurse implement?
A. Give an around-the-clock schedule for administration of
analgesics.
B. Administer analgesic medication as needed when the pain is
severe.
C. Provide medication to keep the client sedated and unaware
of stimuli.
D. Offer a medication-free period so that the client can do daily
activities.
The most effective management of pain is achieved using an
around-the-clock schedule that provides analgesic medications
,on a regular basis (A) and in a timely manner. Analgesics are less
effective if pain persists until it is severe, so an analgesic
medication should be administered before the client's pain peaks
(B). Providing comfort is a priority for the client who is dying,
but sedation that impairs the client's ability to interact and
experience the time before life ends should be minimized (C).
Offering a medication-free period allows the serum drug level to
fall, which is not an effective method to manage chronic pain (D).
Correct Answer: A
When assessing a client with wrist restraints, the nurse
observes that the fingers on the right hand are blue. What
action should the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse.
The priority nursing action is to restore circulation by loosening
the restraint (A), because blue fingers (cyanosis) indicates
decreased circulation. (C and D) are also important nursing
interventions, but do not have the priority of (A). Pulse oximetry
(B) measures the saturation of hemoglobin with oxygen and is
not indicated in situations where the cyanosis is related to
mechanical compression (the restraints).
Correct Answer: A
The nurse is assessing the nutritional status of several clients.
Which client has the greatest nutritional need for additional
intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer.
A lactating woman (B) has the greatest need for additional
protein intake. (A, C, and D) are all conditions that require
protein, but do not have the increased metabolic protein
demands of lactation.
Correct Answer: B
A client is in the radiology department at 0900 when the
prescription levofloxacin (Levaquin) 500 mg IV q24h is
scheduled to be administered. The client returns to the unit at
1300. What is the best intervention for the nurse to
implement?
, A. Contact the healthcare provider and complete a medication
variance form.
B. Administer the Levaquin at 1300 and resume the 0900
schedule in the morning.
C. Notify the charge nurse and complete an incident report to
explain the missed dose.
D. Give the missed dose at 1300 and change the schedule to
administer daily at 1300.
To ensure that a therapeutic level of medication is maintained,
the nurse should administer the missed dose as soon as possible,
and revise the administration schedule accordingly to prevent
dangerously increasing the level of the medication in the
bloodstream (D). The nurse should document the reason for the
late dose, but (A and C) are not warranted. (B) could result in
increased blood levels of the drug.
Correct Answer: D
While instructing a male client's wife in the performance of
passive range-of-motion exercises to his contracted shoulder,
the nurse observes that she is holding his arm above and below
the elbow. What nursing action should the nurse implement?
A. Acknowledge that she is supporting the arm correctly.
B. Encourage her to keep the joint covered to maintain
warmth.
C. Reinforce the need to grip directly under the joint for better
support.
D. Instruct her to grip directly over the joint for better motion.
The wife is performing the passive ROM correctly, therefore the
nurse should acknowledge this fact (A). The joint that is being
exercised should be uncovered (B) while the rest of the body
should remain covered for warmth and privacy. (C and D) do not
provide adequate support to the joint while still allowing for joint
movement.
Correct Answer: A
What is the most important reason for starting intravenous
infusions in the upper extremities rather than the lower
extremities of adults?
A. It is more difficult to find a superficial vein in the feet and
ankles.
B. A decreased flow rate could result in the formation of a
thrombosis.
C. A cannulated extremity is more difficult to move when the
leg or foot is used.
D. Veins are located deep in the feet and ankles, resulting in a
more painful procedure.
Which nursing measure is essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position.
To avoid shearing forces when repositioning, the client should be
lifted gently across a surface (D). Reddened areas should not be
massaged (A) since this may increase the damage to already
traumatized skin. To control pain and muscle spasms, active
range of motion (B) may be limited on the affected leg. The
position described in (C) is contraindicated for a client with a
fractured left hip.
Correct Answer: D
The nurse is administering medications through a nasogastric
tube (NGT) which is connected to suction. After ensuring
correct tube placement, what action should the nurse take
next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water.
The NGT should be flushed before, after and in between each
medication administered (B). Once all medications are
administered, the NGT should be clamped for 20 minutes (A). (C
and D) may be implemented only after the tubing has been
flushed.
Correct Answer: B
A client who is in hospice care complains of increasing
amounts of pain. The healthcare provider prescribes an
analgesic every four hours as needed. Which action should the
nurse implement?
A. Give an around-the-clock schedule for administration of
analgesics.
B. Administer analgesic medication as needed when the pain is
severe.
C. Provide medication to keep the client sedated and unaware
of stimuli.
D. Offer a medication-free period so that the client can do daily
activities.
The most effective management of pain is achieved using an
around-the-clock schedule that provides analgesic medications
,on a regular basis (A) and in a timely manner. Analgesics are less
effective if pain persists until it is severe, so an analgesic
medication should be administered before the client's pain peaks
(B). Providing comfort is a priority for the client who is dying,
but sedation that impairs the client's ability to interact and
experience the time before life ends should be minimized (C).
Offering a medication-free period allows the serum drug level to
fall, which is not an effective method to manage chronic pain (D).
Correct Answer: A
When assessing a client with wrist restraints, the nurse
observes that the fingers on the right hand are blue. What
action should the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse.
The priority nursing action is to restore circulation by loosening
the restraint (A), because blue fingers (cyanosis) indicates
decreased circulation. (C and D) are also important nursing
interventions, but do not have the priority of (A). Pulse oximetry
(B) measures the saturation of hemoglobin with oxygen and is
not indicated in situations where the cyanosis is related to
mechanical compression (the restraints).
Correct Answer: A
The nurse is assessing the nutritional status of several clients.
Which client has the greatest nutritional need for additional
intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer.
A lactating woman (B) has the greatest need for additional
protein intake. (A, C, and D) are all conditions that require
protein, but do not have the increased metabolic protein
demands of lactation.
Correct Answer: B
A client is in the radiology department at 0900 when the
prescription levofloxacin (Levaquin) 500 mg IV q24h is
scheduled to be administered. The client returns to the unit at
1300. What is the best intervention for the nurse to
implement?
, A. Contact the healthcare provider and complete a medication
variance form.
B. Administer the Levaquin at 1300 and resume the 0900
schedule in the morning.
C. Notify the charge nurse and complete an incident report to
explain the missed dose.
D. Give the missed dose at 1300 and change the schedule to
administer daily at 1300.
To ensure that a therapeutic level of medication is maintained,
the nurse should administer the missed dose as soon as possible,
and revise the administration schedule accordingly to prevent
dangerously increasing the level of the medication in the
bloodstream (D). The nurse should document the reason for the
late dose, but (A and C) are not warranted. (B) could result in
increased blood levels of the drug.
Correct Answer: D
While instructing a male client's wife in the performance of
passive range-of-motion exercises to his contracted shoulder,
the nurse observes that she is holding his arm above and below
the elbow. What nursing action should the nurse implement?
A. Acknowledge that she is supporting the arm correctly.
B. Encourage her to keep the joint covered to maintain
warmth.
C. Reinforce the need to grip directly under the joint for better
support.
D. Instruct her to grip directly over the joint for better motion.
The wife is performing the passive ROM correctly, therefore the
nurse should acknowledge this fact (A). The joint that is being
exercised should be uncovered (B) while the rest of the body
should remain covered for warmth and privacy. (C and D) do not
provide adequate support to the joint while still allowing for joint
movement.
Correct Answer: A
What is the most important reason for starting intravenous
infusions in the upper extremities rather than the lower
extremities of adults?
A. It is more difficult to find a superficial vein in the feet and
ankles.
B. A decreased flow rate could result in the formation of a
thrombosis.
C. A cannulated extremity is more difficult to move when the
leg or foot is used.
D. Veins are located deep in the feet and ankles, resulting in a
more painful procedure.
