q qq
Anqelderlyqclientqwithqaqfracturedqleftqhipqisqonqstrictqbedrest.qWhichqnursingqmeasureqisqessentialqtoqth
eqclient'sqnursingqcare?
A. Massageqanyqreddenedqareasqforqatqleastqfiveqminutes.
B. Encourageqactiveqrangeqofqmotionqexercisesqonqextremities.
C. Positionqtheqclientqlaterally,qprone,qandqdorsallyqinqsequence.
D. Gentlyqliftqtheqclientqwhenqmovingqintoqaqdesiredqposition.
Toqavoidqshearingqforcesqwhenqrepositioning,qtheqclientqshouldqbeqliftedqgentlyqacrossqaqsurfaceq(D).qRed
denedqareasqshouldqnotqbeqmassagedq(A)qsinceqthisqmayqincreaseqtheqdamageqtoqalreadyqtraumatizedqski
n.qToqcontrolqpainqandqmuscleqspasms,qactiveqrangeqofqmotionq(B)qmayqbeqlimitedqonqtheqaffectedqleg.qTh
eqpositionqdescribedqinq(C)qisqcontraindicatedqforqaqclientqwithqaqfracturedqleftqhip.
CorrectqAnswer:qD
Theqnurseqisqadministeringqmedicationsqthroughqaqnasogastricqtubeq(NGT)qwhichqisqconnectedqtoqsuction
.qAfterqensuringqcorrectqtubeqplacement,qwhatqactionqshouldqtheqnurseqtakeqnext?
A. Clampqtheqtubeqforq20qminutes.
B. Flushqtheqtubeqwithqwater.
C. Administerqtheqmedicationsqasqprescribed.
D. Crushqtheqtabletsqandqdissolveqinqsterileqwater.
TheqNGTqshouldqbeqflushedqbefore,qafterqandqinqbetweenqeachqmedicationqadministeredq(B).qOnceqal
lqmedicationsqareqadministered,qtheqNGTqshouldqbeqclampedqforq20qminutesq(A).q(CqandqD)qmayqbeqim
plementedqonlyqafterqtheqtubingqhasqbeenqflushed.
CorrectqAnswer:qB
Aqclientqwhoqisqinqhospiceqcareqcomplainsqofqincreasingqamountsqofqpain.qTheqhealthcareqprovide
rqprescribesqanqanalgesicqeveryqfourqhoursqasqneeded.qWhichqactionqshouldqtheqnurseqimplement
?
A. Giveqanqaround-the-clockqscheduleqforqadministrationqofqanalgesics.
B. Administerqanalgesicqmedicationqasqneededqwhenqtheqpainqisqsevere.
C. Provideqmedicationqtoqkeepqtheqclientqsedatedqandqunawareqofqstimuli.
D. Offerqaqmedication-freeqperiodqsoqthatqtheqclientqcanqdoqdailyqactivities.
Theqmostqeffectiveqmanagementqofqpainqisqachievedqusingqanqaround-the-
clockqscheduleqthatqprovidesqanalgesicqmedicationsqonqaqregularqbasisq(A)qandqinqaqtimelyqmanner.qAnalg
esicsqareqlessqeffectiveqifqpainqpersistsquntilqitqisqsevere,qsoqanqanalgesicqmedicationqshouldqbeqadminister
edqbeforeqtheqclient'sqpainqpeaksq(B).qProvidingqcomfortqisqaqpriorityqforqtheqclientqwhoqisqdying,qbutqsedat
ionqthatqimpairsqtheqclient'sqabilityqtoqinteractqandqexperienceqtheqtimeqbeforeqlifeqendsqshouldqbeqminimi
zedq(C).qOfferingqaqmedication-
freeqperiodqallowsqtheqserumqdrugqlevelqtoqfall,qwhichqisqnotqanqeffectiveqmethodqtoqmanageqchronicqpain
q(D).
CorrectqAnswer:qA
Whenqassessingqaqclientqwithqwristqrestraints,qtheqnurseqobservesqthatqtheqfingersqonqtheqrightqhandqar
eqblue.qWhatqactionqshouldqtheqnurseqimplementqfirst?
,A. Loosenqtheqrightqwristqrestraint.
B. Applyqaqpulseqoximeterqtoqtheqrightqhand.
C. Compareqhandqcolorqbilaterally.
D. Palpateqtheqrightqradialqpulse.
Theqpriorityqnursingqactionqisqtoqrestoreqcirculationqbyqlooseningqtheqrestraintq(A),qbecauseqblueqfingersq(c
yanosis)qindicatesqdecreasedqcirculation.q(CqandqD)qareqalsoqimportantqnursingqinterventions,qbutqdoqnotqh
aveqtheqpriorityqofq(A).qPulseqoximetryq(B)qmeasuresqtheqsaturationqofqhemoglobinqwithqoxygenqandqisqnot
qindicatedqinqsituationsqwhereqtheqcyanosisqisqrelatedqtoqmechanicalqcompressionq(theqrestraints).
CorrectqAnswer:qA
Theqnurseqisqassessingqtheqnutritionalqstatusqofqseveralqclients.qWhichqclientqhasqtheqgreatestqnutritiona
lqneedqforqadditionalqintakeqofqprotein?
A. Aqcollege-ageqtrackqrunnerqwithqaqsprainedqankle.
B. Aqlactatingqwomanqnursingqherq3-day-oldqinfant.
C. Aqschool-agedqchildqwithqTypeq2qdiabetes.
D. Anqelderlyqmanqbeingqtreatedqforqaqpepticqulcer.
Aqlactatingqwomanq(B)qhasqtheqgreatestqneedqforqadditionalqproteinqintake.q(A,qC,qandqD)qareqallqcondition
sqthatqrequireqprotein,qbutqdoqnotqhaveqtheqincreasedqmetabolicqproteinqdemandsqofqlactation.
CorrectqAnswer:qB
Aqclientqisqinqtheqradiologyqdepartmentqatq0900qwhenqtheqprescriptionqlevofloxacinq(Levaquin)q500qmgqI
Vqq24hqisqscheduledqtoqbeqadministered.qTheqclientqreturnsqtoqthequnitqatq1300.qWhatqisqtheqbestqinterve
ntionqforqtheqnurseqtoqimplement?
A. Contactqtheqhealthcareqproviderqandqcompleteqaqmedicationqvarianceqform.
B. AdministerqtheqLevaquinqatq1300qandqresumeqtheq0900qscheduleqinqtheqmorning.
C. Notifyqtheqchargeqnurseqandqcompleteqanqincidentqreportqtoqexplainqtheqmissedqdose.
D. Giveqtheqmissedqdoseqatq1300qandqchangeqtheqscheduleqtoqadministerqdailyqatq1300.
Toqensureqthatqaqtherapeuticqlevelqofqmedicationqisqmaintained,qtheqnurseqshouldqadministerqtheqmissedq
doseqasqsoonqasqpossible,qandqreviseqtheqadministrationqscheduleqaccordinglyqtoqpreventqdangerouslyqinc
reasingqtheqlevelqofqtheqmedicationqinqtheqbloodstreamq(D).qTheqnurseqshouldqdocumentqtheqreasonqforqth
eqlateqdose,qbutq(AqandqC)qareqnotqwarranted.q(B)qcouldqresultqinqincreasedqbloodqlevelsqofqtheqdrug.
CorrectqAnswer:qD
Whileqinstructingqaqmaleqclient'sqwifeqinqtheqperformanceqofqpassiveqrange-of-
motionqexercisesqtoqhisqcontractedqshoulder,qtheqnurseqobservesqthatqsheqisqholdingqhisqarmqaboveqand
qbelowqtheqelbow.qWhatqnursingqactionqshouldqtheqnurseqimplement?
A. Acknowledgeqthatqsheqisqsupportingqtheqarmqcorrectly.
B. Encourageqherqtoqkeepqtheqjointqcoveredqtoqmaintainqwarmth.
C. Reinforceqtheqneedqtoqgripqdirectlyqunderqtheqjointqforqbetterqsupport.
D. Instructqherqtoqgripqdirectlyqoverqtheqjointqforqbetterqmotion.
TheqwifeqisqperformingqtheqpassiveqROMqcorrectly,qthereforeqtheqnurseqshouldqacknowledgeqthisqfactq(A)
.qTheqjointqthatqisqbeingqexercisedqshouldqbequncoveredq(B)qwhileqtheqrestqofqtheqbodyqshouldqremainqcov
eredqforqwarmthqandqprivacy.q(CqandqD)qdoqnotqprovideqadequateqsupportqtoqtheqjointqwhileqstill
, allowingqforqjointqmovement.q
CorrectqAnswer:qA
Whatqisqtheqmostqimportantqreasonqforqstartingqintravenousqinfusionsqinqthequpperqextremitiesqrathe
rqthanqtheqlowerqextremitiesqofqadults?
A. Itqisqmoreqdifficultqtoqfindqaqsuperficialqveinqinqtheqfeetqandqankles.
B. Aqdecreasedqflowqrateqcouldqresultqinqtheqformationqofqaqthrombosis.
C. Aqcannulatedqextremityqisqmoreqdifficultqtoqmoveqwhenqtheqlegqorqfootqisqused.
D. Veinsqareqlocatedqdeepqinqtheqfeetqandqankles,qresultingqinqaqmoreqpainfulqprocedure.
Venousqreturnqisqusuallyqbetterqinqthequpperqextremities.qCannulationqofqtheqveinsqinqtheqlowerqextremiti
esqincreasesqtheqriskqofqthrombusqformationq(B)qwhich,qifqdislodged,qcouldqbeqlife-
threatening.qSuperficialqveinsqareqoftenqveryqeasyq(A)qtoqfindqinqtheqfeetqandqlegs.qHandlingqaqlegqorqfootq
withqanqIVq(C)qisqprobablyqnotqanyqmoreqdifficultqthanqhandlingqanqarmqorqhand.qEvenqifqtheqnurseqdidqbeli
eveqmovingqaqcannulatedqlegqwasqmoreqdifficult,qthisqisqnotqtheqmostqimportantqreasonqforqusingqthequpp
erqextremities.qPainq(D)qisqnotqaqconsideration.
CorrectqAnswer:qB
Theqnurseqobservesqanqunlicensedqassistiveqpersonnelq(UAP)qtakingqaqclient'sqbloodqpressureqwithqaqcuffq
thatqisqtooqsmall,qbutqtheqbloodqpressureqreadingqobtainedqisqwithinqtheqclient'squsualqrange.qWhatqactio
nqisqmostqimportantqforqtheqnurseqtoqimplement?
A. TellqtheqUAPqtoquseqaqlargerqcuffqatqtheqnextqscheduledqassessment.
B. Reassessqtheqclient'sqbloodqpressurequsingqaqlargerqcuff.
C. HaveqthequnitqeducatorqreviewqthisqprocedureqwithqtheqUAPs.
D. TeachqtheqUAPqtheqcorrectqtechniqueqforqassessingqbloodqpressure.
TheqmostqimportantqactionqisqtoqensureqthatqanqaccurateqBPqreadingqisqobtained.qTheqnurseqshouldqreass
essqtheqBPqwithqtheqcorrectqsizeqcuffq(B).qReassessmentqshouldqnotqbeqpostponedq(A).qThoughq(CqandqD)qa
reqlikelyqindicated,qtheseqactionsqdoqnotqhaveqtheqpriorityqofq(B).
CorrectqAnswer:qB
Aqclientqisqtoqreceiveqcimetidineq(Tagamet)q300qmgqq6hqIVPB.qTheqpreparationqarrivesqfromqtheqpharmac
yqdilutedqinq50qmlqofq0.9%qNaCl.qTheqnurseqplansqtoqadministerqtheqIVPBqdoseqoverq20qminutes.qForqhowq
manyqml/hrqshouldqtheqinfusionqpumpqbeqsetqtoqdeliverqtheqsecondaryqinfusion?
Theqinfusionqrateqisqcalculatedqasqaqratioqproportionqproblem,qi.e.,q50qml/q20qminq:qxqml/q60qmin.qMultipl
yqextremesqandqmeansq50q×q60q/20xq1=q300/20=150
CorrectqAnswer:q150
Twentyqminutesqafterqbeginningqaqheatqapplication,qtheqclientqstatesqthatqtheqheatingqpadqnoqlongerqfeel
sqwarmqenough.qWhatqisqtheqbestqresponseqbyqtheqnurse?
A. Thatqmeansqyouqhaveqderivedqtheqmaximumqbenefit,qandqtheqheatqcanqbeqremoved.
B. Yourqbloodqvesselsqareqbecomingqdilatedqandqremovingqtheqheatqfromqtheqsite.
C. Weqwillqincreaseqtheqtemperatureq5qdegreesqwhenqtheqpadqnoqlongerqfeelsqwarm.
D. Theqbody'sqreceptorsqadaptqoverqtimeqasqtheyqareqexposedqtoqheat.
(D)qdescribesqthermalqadaptation,qwhichqoccursq20qtoq30qminutesqafterqheatqapplication.q(AqandqB)qpro
videqfalseqinformation.q(C)qisqnotqbasedqonqaqknowledgeqofqphysiologyqandqisqanqunsafeqactionqthat