lOMoARcPSD|13378241
RN Comprehensive Online Practice 2019 A with NGN
A nurse is caring for a client who has hypertension and is taking captopril. Which of the following tasks should the nurse
delegate to an assistive personnel (AP)?
Obtain the client's blood pressure before the nurse administers medication.
The nurse can delegate obtaining blood pressure before and after medication administration because this task is within the range of
function for an AP.
Initiate a referral with a dietitian for the client.
Initiating a referral with a dietitian requires assessment skills and is the role of the nurse.
Inform the client about the adverse effects of the medication.
Informing the client about the adverse effects of a medication is the role of the nurse.
Recommend a salt substitute to the client.
Recommending a salt substitute to the client is the role of the nurse and is outside the range of function for an AP.
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?
Refer the nurse to the procedure manual.
The charge nurse should instruct the newly licensed nurse to consult the procedure manual for further information.
Use a diagram to explain the procedure to the nurse.
The charge nurse should use a diagram to explain the procedure and enhance the nurse's understanding.
Demonstrate the procedure to the nurse.
The charge nurse should use a demonstration to model the procedure to the newly licensed nurse.
Ask the nurse about their knowledge of the procedure.
The first action the charge nurse should take using 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.
A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg (8 lb) and is being breastfed.
Which of the following findings indicates effective breastfeeding?
The newborn nurses every 4 hr during the day and sleeps through the night.
Measuring duration and frequency of nursing is not an effective way to evaluate the effectiveness of breastfeeding.
The newborn has six to eight wet diapers per day.
Measuring the number of wet diapers per day is an effective measurement of adequate intake. Six to eight wet diapers each day
after the fourth day of life indicates effective breastfeeding.
The newborn's current weight is 3.18 kg (7 lb).
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, lOMoARcPSD|13378241
RN Comprehensive Online Practice 2019 A with NGN
A newborn is expected to gain 20 to 28 g (0.04 to 0.06 lb) per day after the fourth or fifth day and surpass the birth weight in 10 to
14 days. Slow weight gain can be an indication of ineffective breastfeeding.
The newborn has sticky, greenish stools.
The breastfed newborn's stool should be yellow, soft, and seedy by the end of the first week of life. Newborns who continue to have
meconium in their stools after the first week of life should be evaluated for ineffective breastfeeding.
A nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. Which of the
following actions should the nurse take first?
Measure the client's vital signs.
The first action the nurse should take when using the nursing process is to assess the client. The nurse should monitor the client's
vital signs every 15 min until stable and then every 4 hr for the next 48 hr.
Reposition the client.
The nurse should reposition the client every 2 hr to prevent postoperative complications such as atelectasis.
Encourage the client to use an incentive spirometer.
The nurse should encourage the client to turn, cough, deep breathe, and use an incentive spirometer every 2 hr for 24 hr to increase
lung expansion and prevent pneumonia.
Administer pain medication.
The nurse should administer pain medication on a regular schedule for the first 48 hr for a client who is postoperative and has vital
signs within the expected reference range following a total vaginal hysterectomy.
A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530
and 0730. Which of the following actions should the nurse take when conducting a root cause analysis?
Investigate environmental factors that might be contributing to client injury during these hours
When conducting a root cause analysis, the nurse should look at the factors that could possibly lead to the clients' falls. This can
include environmental factors that might be causing the problem.
Review the performance evaluations of nurses who work during these hours.
When conducting a root cause analysis, the nurse does not look at the individual performance of staff members.
Implement a plan to transition from team nursing to primary care nursing during these hours.
When conducting a root cause analysis, the nurse should focus on identifying the cause of a problem, not potential solutions to the
problem.
Discuss a plan with the providers to reduce the use of barbiturate sedatives prior to these hours.
When conducting a root cause analysis, the nurse should focus on identifying the cause of a problem, not potential solutions to the
problem.
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, lOMoARcPSD|13378241
RN Comprehensive Online Practice 2019 A with NGN
A nurse is administering cyclophosphamide orally to a school-age child who has neuroblastoma. Which of the following
actions should the nurse take when administering this medication?
Give an antiemetic 30 min after medication administration.
The nurse should administer an antiemetic 30 min before administration of the medication to decrease gastrointestinal effects.
Monitor blood glucose levels.
Cyclophosphamide does not affect blood glucose levels.
Maintain hydration with liberal fluid intake.
The nurse should offer fluids frequently to maintain hydration and prevent hemorrhagic cystitis, which is an adverse effect of this
medication.
Monitor for tumor lysis syndrome.
Tumor lysis syndrome can occur in clients who are diagnosed with acute lymphoblastic leukemia, not neuroblastoma.
A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the
following actions should the charge nurse take first?
Ensure that the staff nurse changes the dressing.
It is the charge nurse's role to advocate for the client to receive the care the provider prescribed.
Notify the nurse manager.
The charge nurse should notify the nurse manager that the occurrence happened.
Complete an incident report.
The charge nurse should complete an incident report describing the occurrence.
Gather more information about the staff nurse's actions.
The first action the nurse should take when using the nursing process is to assess the reasons for the staff nurse's negligent actions.
Therefore, the charge nurse should gather additional information and discuss the issue with the staff nurse before deciding on the
next course of action.
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?
Hypotension
The nurse should instruct the client to monitor for and report hypertension.
Headaches
The nurse should instruct the client to monitor for and report headaches. Headaches can be an indication of a thromboembolic
stroke because estradiol increases the risk for adverse cardiovascular events.
Bruising
Downloaded by phonney tran ()
, lOMoARcPSD|13378241
RN Comprehensive Online Practice 2019 A with NGN
The nurse should instruct the client to monitor for swelling and tenderness of an extremity or fluid retention. Bruising is not an
adverse effect of this medication.
Oliguria
The nurse should instruct the client to monitor for the development of genitourinary candidiasis. Oliguria is not an adverse effect of
this medication.
A nurse is preparing to administer enoxaparin to a client.
Enoxaparin is administered subcutaneous tissue, specifically in the periumbilical area.
B – Deltoid site, used for intramuscular injections.
C – Ventrogluteal site, used for intramuscular injections.
D – Anterior thigh for SQ injection, enoxaparin must be administered in a different area.
A nurse is assessing a client who has skeletal traction for a femur fracture. Which of the following findings should the
nurse identify as the priority?
Muscle spasms of the affected extremity
The nurse should reposition the client or check the weights to relieve the client's muscle spasms.
A pain rating of 6 on a scale from 0 to 10
The nurse should provide analgesia to relieve the client's moderate pain level.
Upper chest petechiae
The greatest risk to this client is organ damage from fat embolism syndrome, a life-threatening complication of fractures. In fat
embolism syndrome, a fat embolism enters the bloodstream and can obstruct blood vessels of a major organ, such as the lung,
kidney, or brain. Manifestations include petechiae on the upper torso, dyspnea, hypoxia, headache, lethargy, and confusion. Therefore,
the nurse should identify this as the priority finding.
Ecchymosis over the fractured area
The nurse should identify ecchymosis over the fractured area as an expected finding due to localized trauma and provide comfort
measures.
Downloaded by phonney tran ()
RN Comprehensive Online Practice 2019 A with NGN
A nurse is caring for a client who has hypertension and is taking captopril. Which of the following tasks should the nurse
delegate to an assistive personnel (AP)?
Obtain the client's blood pressure before the nurse administers medication.
The nurse can delegate obtaining blood pressure before and after medication administration because this task is within the range of
function for an AP.
Initiate a referral with a dietitian for the client.
Initiating a referral with a dietitian requires assessment skills and is the role of the nurse.
Inform the client about the adverse effects of the medication.
Informing the client about the adverse effects of a medication is the role of the nurse.
Recommend a salt substitute to the client.
Recommending a salt substitute to the client is the role of the nurse and is outside the range of function for an AP.
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?
Refer the nurse to the procedure manual.
The charge nurse should instruct the newly licensed nurse to consult the procedure manual for further information.
Use a diagram to explain the procedure to the nurse.
The charge nurse should use a diagram to explain the procedure and enhance the nurse's understanding.
Demonstrate the procedure to the nurse.
The charge nurse should use a demonstration to model the procedure to the newly licensed nurse.
Ask the nurse about their knowledge of the procedure.
The first action the charge nurse should take using 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.
A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg (8 lb) and is being breastfed.
Which of the following findings indicates effective breastfeeding?
The newborn nurses every 4 hr during the day and sleeps through the night.
Measuring duration and frequency of nursing is not an effective way to evaluate the effectiveness of breastfeeding.
The newborn has six to eight wet diapers per day.
Measuring the number of wet diapers per day is an effective measurement of adequate intake. Six to eight wet diapers each day
after the fourth day of life indicates effective breastfeeding.
The newborn's current weight is 3.18 kg (7 lb).
Downloaded by phonney tran ()
, lOMoARcPSD|13378241
RN Comprehensive Online Practice 2019 A with NGN
A newborn is expected to gain 20 to 28 g (0.04 to 0.06 lb) per day after the fourth or fifth day and surpass the birth weight in 10 to
14 days. Slow weight gain can be an indication of ineffective breastfeeding.
The newborn has sticky, greenish stools.
The breastfed newborn's stool should be yellow, soft, and seedy by the end of the first week of life. Newborns who continue to have
meconium in their stools after the first week of life should be evaluated for ineffective breastfeeding.
A nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. Which of the
following actions should the nurse take first?
Measure the client's vital signs.
The first action the nurse should take when using the nursing process is to assess the client. The nurse should monitor the client's
vital signs every 15 min until stable and then every 4 hr for the next 48 hr.
Reposition the client.
The nurse should reposition the client every 2 hr to prevent postoperative complications such as atelectasis.
Encourage the client to use an incentive spirometer.
The nurse should encourage the client to turn, cough, deep breathe, and use an incentive spirometer every 2 hr for 24 hr to increase
lung expansion and prevent pneumonia.
Administer pain medication.
The nurse should administer pain medication on a regular schedule for the first 48 hr for a client who is postoperative and has vital
signs within the expected reference range following a total vaginal hysterectomy.
A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530
and 0730. Which of the following actions should the nurse take when conducting a root cause analysis?
Investigate environmental factors that might be contributing to client injury during these hours
When conducting a root cause analysis, the nurse should look at the factors that could possibly lead to the clients' falls. This can
include environmental factors that might be causing the problem.
Review the performance evaluations of nurses who work during these hours.
When conducting a root cause analysis, the nurse does not look at the individual performance of staff members.
Implement a plan to transition from team nursing to primary care nursing during these hours.
When conducting a root cause analysis, the nurse should focus on identifying the cause of a problem, not potential solutions to the
problem.
Discuss a plan with the providers to reduce the use of barbiturate sedatives prior to these hours.
When conducting a root cause analysis, the nurse should focus on identifying the cause of a problem, not potential solutions to the
problem.
Downloaded by phonney tran ()
, lOMoARcPSD|13378241
RN Comprehensive Online Practice 2019 A with NGN
A nurse is administering cyclophosphamide orally to a school-age child who has neuroblastoma. Which of the following
actions should the nurse take when administering this medication?
Give an antiemetic 30 min after medication administration.
The nurse should administer an antiemetic 30 min before administration of the medication to decrease gastrointestinal effects.
Monitor blood glucose levels.
Cyclophosphamide does not affect blood glucose levels.
Maintain hydration with liberal fluid intake.
The nurse should offer fluids frequently to maintain hydration and prevent hemorrhagic cystitis, which is an adverse effect of this
medication.
Monitor for tumor lysis syndrome.
Tumor lysis syndrome can occur in clients who are diagnosed with acute lymphoblastic leukemia, not neuroblastoma.
A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the
following actions should the charge nurse take first?
Ensure that the staff nurse changes the dressing.
It is the charge nurse's role to advocate for the client to receive the care the provider prescribed.
Notify the nurse manager.
The charge nurse should notify the nurse manager that the occurrence happened.
Complete an incident report.
The charge nurse should complete an incident report describing the occurrence.
Gather more information about the staff nurse's actions.
The first action the nurse should take when using the nursing process is to assess the reasons for the staff nurse's negligent actions.
Therefore, the charge nurse should gather additional information and discuss the issue with the staff nurse before deciding on the
next course of action.
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?
Hypotension
The nurse should instruct the client to monitor for and report hypertension.
Headaches
The nurse should instruct the client to monitor for and report headaches. Headaches can be an indication of a thromboembolic
stroke because estradiol increases the risk for adverse cardiovascular events.
Bruising
Downloaded by phonney tran ()
, lOMoARcPSD|13378241
RN Comprehensive Online Practice 2019 A with NGN
The nurse should instruct the client to monitor for swelling and tenderness of an extremity or fluid retention. Bruising is not an
adverse effect of this medication.
Oliguria
The nurse should instruct the client to monitor for the development of genitourinary candidiasis. Oliguria is not an adverse effect of
this medication.
A nurse is preparing to administer enoxaparin to a client.
Enoxaparin is administered subcutaneous tissue, specifically in the periumbilical area.
B – Deltoid site, used for intramuscular injections.
C – Ventrogluteal site, used for intramuscular injections.
D – Anterior thigh for SQ injection, enoxaparin must be administered in a different area.
A nurse is assessing a client who has skeletal traction for a femur fracture. Which of the following findings should the
nurse identify as the priority?
Muscle spasms of the affected extremity
The nurse should reposition the client or check the weights to relieve the client's muscle spasms.
A pain rating of 6 on a scale from 0 to 10
The nurse should provide analgesia to relieve the client's moderate pain level.
Upper chest petechiae
The greatest risk to this client is organ damage from fat embolism syndrome, a life-threatening complication of fractures. In fat
embolism syndrome, a fat embolism enters the bloodstream and can obstruct blood vessels of a major organ, such as the lung,
kidney, or brain. Manifestations include petechiae on the upper torso, dyspnea, hypoxia, headache, lethargy, and confusion. Therefore,
the nurse should identify this as the priority finding.
Ecchymosis over the fractured area
The nurse should identify ecchymosis over the fractured area as an expected finding due to localized trauma and provide comfort
measures.
Downloaded by phonney tran ()
