1.poTheponurseporemovedpothepodressingpoonpoapoclient'spoheelpothatpoispocoveringpoapopress
ureposorepoone-inchpoinpodiameterpoandpofindspothatpotherepoispostraw-
coloredpodrainageposeepingpofrompothepowound.poWhatpodescriptionpoofpothispofindingposho
uldpotheponursepoincludepoinpothepoclient'sporecord?
a.poStagepo1popressureposorepodrainingposero-sanguineouspodrainage.
b.poPressureposorepoatpobonypoprominencepowithpoexudateponoted.
c.poOne-inchpopressureposorepodrainingposerouspofluid.
d.poPressureposorepoonpohellpowithpoaposmallpoamountpoofpopurulentpodrainage.po-poans--C
Rationale
Serouspodrainagepoispoclearpowaterypoplasma,posopo(C)poprovidespoaccuratepodocumentatio
npobasedpoonpothepoinformationpoprovided.poInformationpotopostagepothispopressureposcorepo
(A)poisponotpoprovided,poandposero-
sanguineouspodrainagepoispopalepoandpowaterypowithpoapocombinationpoofpoplasmapoandpore
dpocells,poandpomaypobepoblood-
streaked.poExudatepo(B)poispofluidposuchpoaspopuspoandposerum.poPurulentpodrainagepo(D)poi
spothick,poyellow,pogreen,poorpobrownpoindicatingpothepopresencepoofpodeadpoorpolivingpoorga
nismspoandpowhitepobloodpocells.
2.poApoclientpoinpohospicepocarepodevelopspoaudiblepogurglingposoundspoonpoinspiration.poW
hichponursingpoactionpohaspothepohighestpopriority?
a.poEnsurepoculturalpocustomspoarepoobserved.
b.poIncreasepooxygenpoflowpotopo4L/minute.
c.poAuscultatepobilateralpolungpofields.
d.poInformpothepofamilypothatpodeathpoispoimminent.po-poans--D
Rationale
Anpoaudiblepogurglingposoundpoproducedpobypoapodyingpoclientpoispocharacteristicpoofpoineffe
ctivepoclearancepoofposecretionspofrompothepolungspoorpoupperpoairways,pocausingpoapo"rattli
ng"posoundpoaspoairpomovespothroughpothepoaccumulatedpofluid.poTheponursingpoprioritypoinp
othisposituationpoispotopoconveypotopothepofamilypothatpothepoclient'spodeathpoispoimminentpo(D
).poAlthoughpoculturallyposensitivepocareposhouldpobepoobservedpothroughoutpothepoclient'spo
planpoofpocarepo(A),pothispoisponotpothepoprioritypoatpothispotime.poAdministrationpoofpooxygenp
omaypobepoexpectedpocare,pobutpoapoflowporatepogreaterpothanpo2poL/
minutepo(B)poisponotpopalliativepocare.po(C)pomaypoprovidepoadditionalpoinformation,pobutpoisp
onotponecessarypoaspodeathpoapproaches.
,3.poTheponursepoispocaringpoforpoapoclientpowhopoispoweakpofrompoinactivitypobecausepoofpoapo
2-
weekpohospitalization.poInpoplanningpocarepoforpothepoclient,potheponurseposhouldpoincludepo
whichpo(ROM)poexercises?
a.poPassivepoROMpoexercisepotopoallpojointspoonpoallpoextremitiespofourpotimespoapoday.
b.poActivepoROMpoexercisespotopobothpoarmspoandpolegspotwopoorpothreepotimespoapoday.
c.poActivepoROMpoexercisespowithpoweightspotwicepoapodaypowithpo20porepetitionspoeach.
d.poPassivepoROMpoexercisespotopothepopointpoofporesistancepoandposlightlypobeyond.po-
poans--B
Rationale
Active,poratherpothanpopassive,poROMpoispobestpotoporestorepostrengthpoandpo(B)poispoanpoeff
ectiveposchedule.poPassivepoROMpo4potimespoapodaypo(A)poisponotpoaspobeneficialpoforpothepo
clientpoaspo(B).poWithpoweightspo(C),pothepoclientpomaypofatiguepoquicklypoandpodeveloppomu
scleposoreness.poROMpoisponotpoperformedpobeyondpothepopointpoofporesistancepoorpopainpo(
D)pobecausepoofpotheporiskpoofpodamagepotopounderlyingpostructures.
4.poTheponursepoispopreparingpoapomalepoclientpowhopohaspoanpoindwellingpocatheterpoandpoa
npoIVpoinfusionpotopoambulatepofrompothepobedpotopoapochairpoforpothepofirstpotimepofollowingpo
abdominalposurgery.poWhatpoaction(s)poshouldpotheponursepoimplementpopriorpotopoassistin
gpothepoclientpotopothepochair?po(Selectpoallpothatpoapply)
a.poPre-medicatepothepoclientpowithpoanpoanalgesic.
b.poInformpothepoclientpoofpothepoplanpoforpomovingpotopothepochair.
c.poObtainpoandpoplacepoapoportablepocommodepobypothepobed.
d.poAskpothepoclientpotopopushpothepoIVpopolepotopothepochair.
e.poClamppothepoindwellingpocatheter.
f.poAssesspothepoclient'spobloodpopressure.po-poans--A,poB,poD,poF
Rationale
Theponurseposhouldpoplanpotopoimplementpo(A,poB,poD,poandpoF).poPre-
medicatingpothepoclientpowithpoanpoanalgesicpo(A)poreducespothepoclient'spopainpoduringpomo
bilizationpoandpomaximizespocompliance.poTopoensurepothepoclient'spocooperationpoandpopr
omotepoindependence,potheponurseposhouldpoinformpothepoclientpoaboutpothepoplanpoforpomo
vingpotopothepochairpo(B)poandpoencouragepothepoclientpotopoparticipatepobypopushingpothepoI
Vpopolepowhenpowalkingpotopothepochairpo(D).poTheponurseposhouldpoassesspothepoclient'spobl
oodpopressurepo(F)popriorpotopomobilization,powhichpocanpocausepoorthostaticpohypotension.
po(CpoandpoE)poareponotpoindicated.
5.poTheponursepoispoadministeringpoanpointermittentpoinfusionpoofpoanpoantibioticpotopoapoclie
ntpowhosepointravenouspo(IV)poaccesspoispoanpoantecubitalposalinepolock.poAfterpotheponurse
poopenspotheporollerpoclamppoonpothepoIVpotubing,pothepoalarmpoonpothepoinfusionpopumppoind
icatespoanpoobstruction.poWhatpoactionposhouldpotheponursepotakepofirst?
a.poCheckpoforpoapobloodporeturn.
,b.poRepositionpothepoclient'spoarm.
c.poRemovepothepoIVpositepodressing.
d.poFlushpothepolockpowithposaline.po-poans--B
Rationale
Ifpothepoclient'spoelbowpoispobent,pothepoIVpomaypobepounablepotopoinfuse,poresultingpoinpoanpo
obstructionpoalarm,posopotheponurseposhouldpofirstpoattemptpotoporepositionpothepoclient'spoar
mpotopoalleviatepoanypoobstructionpo(B).poAfterpootherposourcespoofpoocclusionpoarepoelimina
ted,potheponursepomayponeedpotopocheckpoforpoapobloodporeturnpo(A),poremovepothepodressin
gpo(C),poorpoflushpotheposalinepolockpo(D)poandpothenporesumepothepointermittentpoinfusion.
6.poInpoassessingpoapoclient'spofemoralpopulse,potheponursepomustpousepodeeppopalpationpoto
pofeelpothepopulsationpowhilepothepoclientpoispoinpoaposupinepoposition.poWhatpoactionposhould
potheponursepoimplement?
a.poElevatepothepoheadpoofpothepobedpoandpoattemptpotopopalpatepothepositepoagain.
b.poDocumentpothepopresencepoandpovolumepoofpothepopulsepopalpated.
c.poUsepoapothighpocuffpotopomeasurepothepobloodpopressurepoinpothepoleg.
d.poRecordpothepopresencepoofpopittingpoedemapoinpothepoinguinalpoarea.po-poans--B
Rationale
Deeppopalpationpomaypobeporequiredpotopopalpatepothepofemoralpopulse;poand,powhenpopalp
ated,potheponurseposhouldpodocumentpothepopresencepoandpovolumepoofpothepopulsepo(B).po
Thepositepoispobestpopalpatedpowithpothepoclientposupine;poelevationpoofpothepoheadpoofpothepo
bedporequirespoevenpodeeperpopalpationpo(A).poThepousepoofpodeeppopalpationpotopofeelpothe
pofemoralpopulsepodoesponotpoindicatepoapoproblemporequiringpofurtherpoassessment,posuchp
oaspo(C),poandpodoesponotporeflectpothepopresencepoofpoedemapo(D).
7.poAponursepoispopreparingpotopoinsertpoaporectalposuppositorypoandpoobservespoaposmallpoa
mountpoofporectalpobleeding.poWhatpoactionposhouldpotheponursepoimplement?
a.poAdministerpothepomedicationpoasposcheduledpoafterpoassessingpothepoclient'spovitalposig
ns.
b.poAskpothepopharmacistpotoposendpoanpoalternatepoformpoofpothepoprescribedpomedicationpo
topothepounit.
c.poWithholdpothepoadministrationpoofpotheposuppositorypountilpocontactingpothepohealthcarep
oprovider.
d.poInsertpotheposuppositorypoverypogentlypobeingpocarefulponotpotopofurtherpoinjurepotheporect
alpomucosa.po-poans--C
Rationale
Thepopresencepoofporectalpobleedingpoispogenerallypoapocontraindicationpoforpothepoinsertion
poofpoaporectalposuppository,posopotheponurseposhouldpowithholdpothepomedicationpoandponoti
fypothepohealthcarepoproviderpo(C).po(ApoandpoD)pomaypocausepoincreasedporectalpobleeding
.poPriorpotopoaskingpothepopharmacistpoforpoanotherpoformpoofpothepomedication,potheponursep
omustpohavepoaponewpoprescriptionpofrompothepohealthcarepoproviderpo(B).
, 8.poApoclientpowhopohaspomoderate,popersistent,pochronicponeuropathicpopainpoduepotopodiab
eticponeuropathypotakespogabapentinpo(Neurontin)poandpoibuprofenpo(Motrin,poAdvil)podaily.
poIfpoSteppo2poofpothepoWorldpoHealthpoOrganizationpo(WHO)popainporeliefpoladderpoispopresc
ribed,powhichpodrugpoprotocolposhouldpobepoimplemented?
a.poContinuepogabapentin.
b.poDiscontinuepoibuprofen.
c.poAddpoaspirinpotopothepoprotocol.
d.poAddpooralpomethadonepotopothepoprotocol.po-poans--A
Rationale
BasedpoonpothepoWHOpopainporeliefpoladder,poadjunctpomedications,posuchpoaspogabapenti
npo(Neurontin),poanpoantiseizurepomedication,pomaypobepousedpoatpoanyposteppoforpoanxietyp
oandpopainpomanagement,posopo(A)poshouldpobepoimplemented.poNonopiodpoanalgesics,pos
uchpoaspoibuprofenpo(A)poandpoaspirinpo(C)poarepoSteppo1podrugs.poSteppo2poandpo3poinclude
poopioidponarcoticspo(D),poandpotopomaintainpofreedompofrompopain,podrugsposhouldpobepogiv
enpo"aroundpothepoclock"poratherpothanpobypothepoclient'spoPRNporequests.
9.poTheponursepooverhearspothepohealthcarepoproviderpoexplainingpotopothepoclientpothatpoth
epotumorporemovedpowasponon-
malignantpoandpothatpothepoclientpowillpobepofine.poHowever,potheponursepohasporeadpoinpothe
popathologyporeportpothatpothepotumorpowaspomalignantpoandpothatpotherepoispoextensivepom
etastasis.poWhoposhouldpotheponursepoconsultpowithpofirstporegardingpotheposituation?
a.poHealthcarepoprovider.
b.poClient'spofamily.
c.poCasepomanager.
d.poChiefpoofpostaff.po-poans--A
Rationale
Theponurseposhouldpoaddresspothepohealthcarepoproviderpowithpothepowrittenporeportpoandpo
discusspowhypohe/shepodidponotpotellpothepoclientpothepotruth--
thispomaypobepoatpothepofamily'sporequestpo(A).po(B,poC,poandpoD)pomaypobepoindicated,pobutp
ofirstpotheponurseposhouldpoconferpowithpothepohealthcarepoproviderpotopoobtainpoallponeeded
poinformation.
10.poTheponursepoencountersporesistancepowhenpoinsertingpothepotubingpointopoapoclient'spor
ectumpoforpoapotappowaterpoenema.poWhatpoactionposhouldpotheponursepoimplement?
a.poWithdrawpothepotubepoandpoapplypoadditionalpolubricantpotopothepotube.
b.poEncouragepothepoclientpotopobearpodownpoandpocontinuepotopoinsertpothepotube.
c.poRemovepothepotubepoandpocheckpothepoclientpoforpoapofecalpoimpaction.
d.poAskpothepoclientpotoporelaxpoandporunpoaposmallpoamountpoofpofluidpointopotheporectum.po-
poans--D