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Scenario 1: A nurse is caring for an infant who is to undergo surgery. The nurse should identify which of the following individuals should sign the consent form? A. The infant's 17-year-old mother B. The infant's provider C. The infant's grandmother D. The mother's 21-year-old sibling Correct Answer: A. The infant's 17-year-old mother Rationale: Generally, a parent or legal guardian has the legal authority to provide consent for medical treatment for a minor. Even though the mother is a minor herself (under 18), many jurisdictions have laws allowing minor parents to consent to medical care for their children. The provider explains the procedure but does not sign the consent. The grandmother and the mother's sibling do not typically have legal authority unless they are the legal guardians. Scenario 2: A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse use? A. Encourage the client to try to defecate for 20 min while on the fracture pan. B. Keep the bed flat while the client is on the fracture pan. C. Hyperextend the client's back while the fracture pan is in place. D. Place the shallow end of the fracture pan under the client's buttocks. Correct Answer: D. Place the shallow end of the fracture pan under the client's buttocks. Rationale: Fracture bedpans are designed with a lower and shallower end to facilitate placement under clients with mobility limitations, such as those in casts, minimizing discomfort and the need for significant lifting or repositioning. Encouraging defecation
for a fixed long period (20 minutes) is not always appropriate. Keeping the bed flat can make it harder for the client to use the bedpan. Hyperextending the back could cause pain or injury. Scenario 3: A nurse is reviewing the medical record of a client who asks about the use of magnet therapy for pain relief. The nurse should identify which of the following findings is a contraindication for receiving this type of therapy? A. The client is allergic to penicillin B. The client has a prescription for metoprolol C. The client has a history of alcohol use disorder D. The client has an implanted defibrillator Correct Answer: D. The client has an implanted defibrillator Rationale: Magnet therapy is contraindicated for clients with implanted electronic devices like defibrillators and pacemakers because the magnetic fields can interfere with the function of these devices, potentially leading to serious adverse events. Allergies, beta-blockers like metoprolol, and a history of alcohol use disorder are generally not contraindications for magnet therapy, although the nurse should still consider the client's overall health status. Scenario 4: A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the client's room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first? A. Gloves B. Eyewear C. Gown D. Mask Correct Answer: A. Gloves Rationale: The gloves are the most contaminated piece of PPE. Removing them first minimizes the risk of transferring microorganisms to oneself or the environment during the removal of other PPE. The correct order for removing PPE after airborne precautions is typically gloves, eyewear, gown, and then mask (outside the patient's room). Scenario 5: A nurse is teaching a newly licensed nurse about the care of a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. Your partner must be present when you sign the advance directives. B. You will receive written information about advance directives prior to signing. C. You are required to sign advance directives prior to surgery. D. Your provider must sign the advance directives before surgery. Correct Answer: B. You will receive written information about advance directives prior to signing. Rationale: Clients have the right to receive information about advance directives, which are legal documents outlining their wishes for medical treatment in the event they become unable to make decisions for themselves. While encouraged, signing advance directives is not always a requirement for surgery. A witness is usually required for signing, but it doesn't have to be the partner. The provider does not typically sign the client's advance directives. Scenario 9: A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take? A. Remove one restraint at a time. Rationale: When providing care to a client in restraints, it is important to maintain safety while allowing for assessment and hygiene. Removing one restraint at a time allows for limb movement and skin assessment while still ensuring the client's safety and preventing the removal of all restraints simultaneously. Scenario 10: A nurse is preparing to administer several medications via NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take? A. Dilute each crushed medication with sterile water. B. Mix the medications together in a single syringe. C. Flush the NG tube with 15-30 mL of sterile water prior to administration. D. Combine the medications with the formula in the feeding bag. Correct Answer: C. Flush the NG tube with 15-30 mL of sterile water prior to administration. Rationale: The NG tube should be flushed with water before administering medications to ensure patency and prevent interactions between medications and the feeding formula. Each medication should ideally be administered separately and flushed with water in between to prevent clogging and interactions. Diluting crushed medications is generally recommended, but flushing the tube before is the priority action in this list. Medications should never be mixed directly with the feeding formula.
Scenario 11: A nurse is planning care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the client's plan of care? A. Toilet the client every 4 hours while the client is awake. B. Apply a moisture barrier in a thick layer to vulnerable skin areas. C. Cleanse the skin with antibacterial soap and hot water after each incontinence episode. D. Reduce the client's daily fluid intake. Correct Answer: B. Apply a moisture barrier in a thick layer to vulnerable skin areas. Rationale: Urinary incontinence can lead to skin breakdown due to prolonged exposure to moisture. Applying a moisture barrier helps to protect the skin from irritation and breakdown. Scheduled toileting (every 2-3 hours, not 4) can be helpful for some types of incontinence. Harsh soaps and hot water can dry and irritate the skin. Restricting fluids is generally not recommended as it can lead to dehydration and constipation; the focus should be on managing the incontinence. Scenario 12: A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus. Which of the following actions should the nurse take first? A. Complete an incident report. B. Obtain the client's vital signs. C. Document the fluid infusion in the client's chart. D. Report the incident to the unit manager. Correct Answer: B. Obtain the client's vital signs. Rationale: Administering double the prescribed dose of IV fluids is a medication error that could have adverse effects on the client, such as fluid overload. The nurse's immediate priority is to assess the client for any signs or symptoms of this complication by checking vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) and assessing for other signs of fluid overload. After ensuring the client's immediate safety, the nurse would then proceed with reporting the error and completing an incident report. Scenario 13: A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply) A. I need to check my medications for expiration dates.
Rationale: Electrical sparks indicate a potential electrical hazard. The nurse's immediate priority is to ensure safety by disconnecting the faulty equipment to prevent electrical shock or fire. After unplugging the pump, the nurse would then obtain a replacement, notify the biomedical department, and label the defective equipment. Scenario 17: A nurse is caring for a client who is receiving a warm, moist compress to relieve lower back pain. Which of the following findings should indicate to the nurse that the compress has been effective? A. The client's skin on the lower back is intact without redness. B. The client is laughing at a television show. C. The client states that he is able to concentrate while eating. D. The client's vital signs are within the expected reference range. Correct Answer: C. The client states that he is able to concentrate while eating. Rationale: The purpose of a warm, moist compress for pain is to provide comfort and reduce pain. The client's ability to concentrate while eating suggests a reduction in pain that was previously interfering with their focus. Intact skin without redness indicates the compress was applied safely. Laughing at a TV show and stable vital signs do not directly indicate pain relief from the compress. Scenario 18: A nurse is preparing a sterile field to assist with suturing a client's laceration. Which of the following actions should the nurse plan to take? B. Hold the bottle of sterile solution so that the label is facing the palm of the hand. Rationale: Holding the sterile solution bottle with the label facing the palm prevents any drips from the label from contaminating the sterile field as the solution is poured. Pouring from 20 cm (8 inches) might be too high, increasing the risk of splashing. The lid of a sterile solution bottle should be placed face up on a clean surface (not the sterile drape) to maintain sterility of the inside of the lid. Sterile gloves are applied after opening sterile packages and before handling sterile supplies. Scenario 19: A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse? D. This test will provide information about the function of your liver. Rationale: Alanine aminotransferase (ALT) is an enzyme primarily found in the liver. Elevated ALT levels can indicate liver damage or disease.^1 The test is not directly related to heart function, blood clot risk, or kidney function.
Scenario 20: A nurse receives a new prescription over the telephone from a client's provider. Which of the following actions should the nurse take first? B. Write down the complete prescription. C. Read back the prescription to the Dr. Rationale: The critical steps for receiving a telephone order are to first write down the complete prescription accurately, including the client's name, medication name, dosage, route, frequency, and time of administration. Immediately after writing it down, the nurse must read back the entire prescription to the provider to ensure accuracy and correct any misunderstandings. While documentation and provider signature are important, verifying the order by reading it back is the immediate priority for patient safety. Scenario 21: A nurse is caring for a client who is on bed rest following abdominal surgery. Which of the following findings indicates the need to increase the frequency of position changes? D. Non-blanching darkened area over the client's trochanter. Rationale: A non-blanching darkened area over a bony prominence like the trochanter is a sign of a potential or developing pressure ulcer (ischemia due to prolonged pressure). This indicates that the current frequency of position changes is insufficient to relieve pressure and maintain skin integrity, thus requiring more frequent repositioning. Petechiae are small hemorrhages, a flat rash could be various skin conditions, and a non-palpable macule is a flat, discolored spot that doesn't necessarily indicate pressure damage. Scenario 22: A nurse is providing teaching to a client who has a newly prescribed hearing aid. Which of the following statements by the client indicates an understanding of the teaching? D. I should gradually increase the time that I wear the hearing aid. Rationale: Clients new to hearing aids often need to adjust to the amplified sounds. Gradually increasing the wearing time allows the client to adapt and prevents discomfort or overwhelming sensory input. Turning the hearing aid up high initially can be uncomfortable and not allow for proper adjustment. Batteries should be removed when the hearing aid is not in use to conserve power and prevent corrosion. Hearing aids do not typically need to be replaced annually; their lifespan depends on various factors. Scenario 23: A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take? A. Collect the sputum specimen in the morning.
D. Recap the needle before disposal - - correct ans- - Discard the needle in a puncture proof container A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage? A. Assist the client in setting goals to make the change B. Develop a plan for the client to integrate the change into her lifestyle C. Present information about the benefits of quitting smoking D. Recommend small changes for the client to make to change her behavior overtime - - correct ans- - Present information about the benefits of quitting smoking A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the following statements made by the client indicates an understanding of the teaching? A. I will keep my legs crossed while sitting B. I will perform exercises once every 4 hours while i am awake C. I should massage my legs when they hurt D. I should limit the time that i spend sitting in a chair - - correct ans- - I should limit the time that i spend sitting in a chair A nurse is documenting client care. Which of the following abbreviations should the nurse use? a. BRP for bathroom privileges - - correct ans- - BRP for bathroom privileges A nurse who is documenting information in a clients electronic medical record is asked to assist with an emergency. Which of the following actions should the nurse take? A. Ask another nurse to monitor the computer B. Turn the computer off C. Move the computer to a secure place
D. Print out the current notes to finish later - - correct ans- - Move the computer to a secure place A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?' A. Diarrhea one time in a 24 hour period B. A weight gain of 0.91kg(2Ib) in 2 days C. A gastric residual of 300mL at the end of the shift D. A blood glucose level of 110 mg/dL - - correct ans- - Diarrhea one time in a 24 hour period A nurse is planning care for a female client who has an indwelling urinary catheter.Which of the following actions should the nurse include in the plan? A. Tape the catheter to the lower abdomen B. Attach the drainage bag to the side rails of the bed C. Keep the drainage bag below the level of the bladder D. Empty the drainage bag when it is three quarters full - - correct ans- - Keep the drainage bag below the level of the bladder A nurse is reviewing the medical record for a newly admitted client. Which of thefollowing laboratory values should the nurse report to the provider? A. Sodium 140 B. Potassium 1. C. Magnesium 1. D. Calcium 6.5 - - correct ans- - Potassium 1. A nurse is preparing to administer gentamicin 2 mg/kg IV to a client who weighs 220Ib. How many mg should the nurse administer? (Round to the nearest whole number.Use a leading zero if it applies. Do not use trailing zero). DOSAGE CALCULATION - - correct ans- - 200 mg
B. Flex the client's knees C. Place the client at the side of the bed nearest the direction they will be turned D. Roll the client as one unit in a smooth continuous motion. - - correct ans- - Roll the client as one unit in a smooth continuous motion A nurse is caring for a client who has TB. which of the following precautions should the nurse plan to implement when working with the client? a. airborne - - correct ans- - airborne A nurse is implementing seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse place at the client's bedside? - - correct ans- - Oral suction equipment, oral airway, and oxygen A nurse is providing teaching to the family of a client who is at the end stage of life. Which of the following client manifestations should the nurse instruct the family to expect? A. Increased periods of wakefulness B. Altered breathing patterns C. Increased salivation D. Warm and dry extremities - - correct ans- - Altered breathing patterns A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse and is scheduled for surgery. Which of the following actions should the nurse take? a. recommend an interpreter who is the same gender as the client. - - correct ans- - recommend an interpreter who is the same gender as the client A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take? a. Aspirate residual volume every 4 hr - - correct ans- - Aspirate residual volume every 4 hr
A nurse is preparing to insert an IV catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating IV therapy? a. The cephalic vein in the left distal forearm - - correct ans- - The cephalic vein in the left distal forearm A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet? a. Plain yogurt - - correct ans- - plain yogurt A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care? a. Schedule the client as the first procedure - - correct ans- - Schedule the client as the first procedure Type 2 diabetes mellitus patient with corns and calluses. a. I can apply lotion to soften calluses as long as i don't put lotion between my toes - - correct ans- - I can apply lotion to soften calluses as long as i don't put lotion between my toes A nurse is caring for a male client who has a prescription for intermittent catheterization with a coude catheter. Which of the following images show the type of catheter the nurse should use? - - correct ans- - Bent tip catheter A nurse is caring for a client following a bilateral mastectomy. The client is often tearful and avoids looking at her dressings. Which of the following actions should the nurse take first? A. Provide the client with a mirror to look at her mastectomy incisions B. refer the client to a breast cancer support group C. identify the impact of the mastectomy on the client's body image
A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the following interventions is the priority? a. Develop a list of goals - - correct ans- - Develop a list of goals What do nurses use when preparing change-of-shift report? - - correct ans- - Standard handoff communication tools, such as Introduction, Situation, Background, Assessment, Recommendation (ISBAR) to facilitate transfers and discharges. When should discharge planning begin? - - correct ans- - On admission with every patient. Discharge documentation should include - - correct ans- - Type of discharge, date & time of discharge, who went with the client & transportation, where the client went, summary of clients current condition at discharge, description of any unresolved difficulties and disposition of valuables, medications brought from home & prescriptions. Documentation & abbreviations and symbols - - correct ans- - Being accurate & concise is an important element of documentation. Only abbreviations & symbols approved by The Joint Commission and the facility are acceptable. A nurse is discussing the HIPPA privacy rule with nurses during new employee orientation. Which of the following information should the nurse include? - - correct ans- - Family members should provide a code prior to receiving client health information Communication of a client can occur at the nurse's station A client can request a hard copy of their records Nurses may photocopy a client's medical record for transfer to another facility. A nurse is receiving a providers prescription for morphine by telephone for a client who is reporting moderate to severe pain. What are the appropriate nursing actions? - -
correct ans- - Repeat the details of the prescription back to the provider, have another nurse listen to the telephone prescription and obtain the providers signature on the prescription within 24 hours. A problem is an ethical dilemma when - - correct ans- - I. A review of scientific data is not enough to solve it II. It involves a conflict between two moral imperatives III. The answer will have a profound effect on the situation and the client Ethical dilemmas are problems that - - correct ans- - involve more than one choice and stem from differences in the values and beliefs of decision makers Autonomy - - correct ans- - the right to makes one's own personal decisions, even when those decisions might not be in the that person's best interest. Beneifience - - correct ans- - positive actions to help others (do good) Fidelity - - correct ans- - agreement to keep promises Justice - - correct ans- - fairness in care delivery and use of resources Nonmaleficence - - correct ans- - avoidance of harm or injury (do no harm) Admission inventory of personal items include - - correct ans- - clothing, jewelry, money, credit cards, assistive devices, medications, cell phones and other technology devices, and religious articles... Nurses should discourage keeping valuables at the bedside. The nurse will document what related to personal items? - - correct ans- - The nurse will document communication with the client related to items left within the room and valuables locked in the facility's safe.
What should clients with hypoglycemia do? - - correct ans- - Take 10 to 30 g of readily absorbed carbohydrate. Including two or three glucose tablets, six to ten hard candies, 1/2 cup of soda or juice, 1 tbsp honey or 4 tsp sugar. What should clients do when levels stabilize? (Hypoglycemia) - - correct ans- - Have the client take an additional carbohydrate and protein snack of small meal. What information should the nurse provide to a client with a new diagnosis of diabetes mellitus type 1? - - correct ans- - Usually occurs before the age 30, is treated with oral antiglycemic medications and regular exercise can reduce insulin requirements. What instructions should the nurse include when reinforcing dietary teaching to a client with type 2 diabetes mellitus? - - correct ans- - Carbohydrate intake should compromise of 55% of daily caloric intake, you can add table sugar to cereal, you can drink one alcoholic beverage with a meal and use the same portion size to exchange carbohydrates. What information should the nurse incorporate into the dietary plan for a client with type 2 diabetes mellitus? - - correct ans- - Weight management, lipid profile, cultural needs, and personal preferences. A nurse is caring for a family experiencing a crisis. What approach should the nurse use when working with a family using an open structure for coping with crisis? - - correct ans- - Convening a family meeting. What should you do before administering any medications? - - correct ans- - Obtain a complete medication and allergy history. What does diphenhydramine treat in relation to allergic reactions? - - correct ans- - Mild rashes and hives
What should you do after hand-washing with ostomy skin care? - - correct ans- - Apply gloves & inspect the stoma, use mild soap and water to cleanse, then dry it gently and completely. What are the steps to take when administering a large-volume enema? - - correct ans- -
- Position the client on the left side with right leg flexed forward. Put on gloves. Lubricate rectal tube or nozzle. (Also, warm to enema solution).
- Slowly insert rectal tube (3 to 4 inches for an adult). Raise bag above anus, 18 inches (if client reports abd cramping, lower the enema fluid container). Ask the client to retain the solution for prescribed amount of time, or until client is no longer able to retain it.
- Discard bag. Assist the client to the appropriate position to defecate. Document results and the client's tolerance of the procedure. What should the nurse do to help prevent plantar flexion? - - correct ans- - Encourage active or provide passive ROM two or three times/day. Instruct clients to perform ROM while bathing, eating, grooming, and dressing. What should be done for a client to promote a proper sleep-wake cycle? - - correct ans-
- Cluster care. ` Who is a fracture pan used for? - - correct ans- - Supine client and clients in body casts or leg casts. What should the nurse do for clients using a fracture pain? - - correct ans- - Raise the head of the bed to 30 degrees. If the client cannot lift his hips to get the bedpan under him, roll him onto one side, position the bedpan over his buttocks, and roll the client back onto the bedpan. Signs/symptoms of extracellular fluid volume deficit - - correct ans- - 1. Hypothermia, tachycardia, thready pulse, orthostatic hypotension, decreased central venus pressure, tachypnea, and hypoxia.
- Dizziness, syncope, confusion, weakness and fatigue.
